HomeMy WebLinkAbout0200 LUMBERT MILL ROAD - Health 200 LUMBERT MILLS RD.
CENTERVILLE
A = 168 074
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UPC 12534
No.2-1 LOR i$4vov
,IACTIN9o.UN
TOWN OF BARN STABLE
LOCATIO a-2 _GI'? mac' it Iey. SEWAGE #
,PILLAGE[ �?41e"c y /te— ASSESSOR'S MAP 6'{LOT
INSTALLER'S NAME a PHONE NO. A & B CAX-Q` -^" : `k 775-6264
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SEPTIC TANK CAPACITY 6j('i�
LEACHING FACILITY:(typew,ja, 61 1-0,e ..Ae<.r(size)c;r�-X/3 Y ,2
NO.OF BEDROOMS- _PRIVATE WELL PUBL WATER.+
BUILDER O OWNE 04A J
DATE PERMIT ISSUED:
F.
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No. 7_()c).I ^V d 0 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Migpooaf bpotem Comaruction Permit
Application for a Permit to Construct( )Repair(L- (pgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No.o?oU iC Urn be 4 Owner's Name,Address and Tel.No.
�w�12�1L1,� KQ,��.eeti1 f�vet-q��nl
Assessor's Map/Parcel 169 O J A„vVe—.
Installer's Name,Ades&al§Td fijgCO Designer's Name,Address and Tel.No.
350 Main Street
W. YarmoUthi MA 02673
Type of Building:
Dwelling- No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 o gallons per day. Calculated daily flow 3 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /ouv Type of S.A.S. . /ea.c a hAMbePS
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
.,S/ra !�!-4( lecec c AIM ,ems t,)Z y" S&fi c
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 Board of He It
Signed I Date /• /7' y
Application Approved by L�.tZlA.vl � Date
Application Disapproved for the following reasons
Permit No. ZQ0 620 Date Issued 1 7J O 1
TOWN OF BARNSTABLE
LOCATIOIj,2,�j .—SEWAGE
VILLAGE( � �,� ASSESSOR'S MAP Si LOT
INSTALLER'S NAME &'PHONE NO. A.& B CANCO 775-6264
SEPTIC TANK CAPACITY. j(>� i'r1Q
i LEACHING FACILITY:(type)gP , ( � e�1 C'Ae ee<5(size)v`2,5 X/.3 ,y
I; NO. OF BEDROOMS_ PRIVATE WELL PUBL WATER
BUILDER OC(?! 4E .04&,;
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED;
;_ ;ViRIANC
i
E°GR14i�1TEDc Yes No
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i `
No. ZC�'!� ^V JlJ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS
2pprfcatfon for Mfgpogar bpgtem Construction Permit
Application for a Permit to Construct( )Repair(✓Upgrade( )Abandon( ) ❑Complete System .G❑Individual Components
Location Address or Lot No. U u /11 h e f ` Owner's Name,Address and Tel.No.
Xj e t�
Assessor's Map/Parcel /6 O / 3 A
Installer's Name,AddW,&n18TeftfilC0 Designer's Name,Address and Tel.No.
350 Main Street N//4
W. Yarmouth M
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 5 gallons.
Plan Date Number of sheets Revision Date
Title i
Size of Septic Tank /v ' ' Type of S.A.S. ,0o 15, l ec(c
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) S/A
5
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 Board of He It
Signed J!) ( CC"4 Date 7' 0/
Application Approved by V_.QlR-yn C<,�V� Date 1//-710 1
Application Disapproved for the following reasons
Permit No. 7 ( " 30 Date Issued ( 7 J U P
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS ��. �
(certificate of (compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( ,'Upgraded( )
Abandoned( )by �'/��llC U
at a7Uo e�;i,f�r� ��e has been constructed in /accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 200'-= dated 1
Installer Designer 4. 4 !
The issuance of this perlt s 1 n t con trued as a guarantee that the s e mil fun do as psi ne
Date Inspector
V I
---------------------------------------
No. ZG0/ W 0 Fee U
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS
Mfgpoga[ *p! tem Congtructfon Permit
Permission is hereby granted to Construct( )Repair(-`5-Upgrade( )Aba don( )
System located at c7 00 G 1 t'716e/ I /1 17, X/e
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: ITI Ca I Approved by 'Le i.k, �� ��
I
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 (WIT OUT DESIGNED PLANS)
I, J l� �,nr�, ,, , hereby certify that the application for disposal works
construction permit signed by me dated / — /7 - o / , concerning the
property located at o7 CTp Lm 6k4 //L d meets all of the
following criteria:
This 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) l ( r
B) G.W.Elevation /•S +the MAX. High G.W.Adjustment. �•� _
DIFFERENCE BETWEEN A and B (• 3
SIGNED : u DATE:
[Please Sketch proposed plan of system on back].
NOTICE
Based upon the above information,a repair permit will be issued for_3 bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
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. TOWN OF BARNSTABLE
LOCATION Z 0C) L�Vt 6A^"t-/�I a7 teo SEWAGE #
VILLAGE 61,11,14, 4,t ASSESSOR'S MAP & LOTI do'`0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �OQQ W r'
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER 0� /� `Zeal
PERMITDATE✓ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) ` Feet
7
Furnished by -+'"-�� ���/
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Commonweci th of Mossochusetts
Executhe Office of Environmental Affcdrs John Grad
D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Environmental Protection Teaticket,MA 02536
(508) 564-6813
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
PART A AA__
CERTIFICATION
O Property Address: 200 Lumbert Mill Rd.Centerville Address of Owner: RS 7 %O W
Date of Inspection:4128197 (if different) , -19,
Name of Inspector:John Gracl Mcleod e�
Company Name,Address and Telephone Number:
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:
X Passes This Inspection is based on criteria defined In Title V
_ Conditionally Passes code 310 CMR 15.303.MV findings are of how the system is
Needs rth Evaluation 8 the Local Approving Authority performing at the time of the Inspection.My Inspection does
Y PP 9 tY not Imply any warranty or guarantee of the longevity of the
Fails septic system and any of its components useful life.
�J .
Inspector's Signature: A, Date: 518197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(36)days of completing this
inspections. 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, B,C, or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
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, 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 11115195)
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 9 Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 200 Lumbert MITI Rd.Centerville
Owner: Mcleod
Date of Inspection:4128197
Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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:
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 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a Septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
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.
Backup of sewage in 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 200 Lumbert MITI Rd.Centerville
Owner: Mcleod
Date of Inspection:4128197
D] SYSTEM FAILS(continued)
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).
Numbers 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 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. 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:
The following criteria apply to large systems in addition to the criteria:
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:
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.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 200 Lumbert Mill Rd.Centerville
Owner: Mcleod
Date of Inspection:4128197
Check if the following have been done:
x Pumping information was requested of the owner,occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
NaAs built plans have been obtained and examined. Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage back-up.
x The system does not receive non-sanitary or industrial waste flow.
x The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered,opened, and the Interior of the septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge, depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 1'1115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 200 Lumbert MITI Rd.Centerville
Owner: Mcleod
Date of Inspectlon:4128197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: Iva
Last date of occupancy: 2 years ago
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n1a
System pumped as part of inspection:(yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
Approximately 20 years.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Lumbert MITI Rd.Centerville
Owner: Mcleod
Date of Inspection:4128197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'8'H 5'7"W 4'10'empty
Sludge depth:0
Distance from top of sludge to bottom of outlet tee or baffle: 0
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:0
Distance form bottom of scum to bottom of outlet tee or baffle:0
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
The septic tank and all components are structurally sound.Recommend pumping the system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
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.)
nla
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Lumbert MITI Rd.Centerville
Owner: Mcleod
Date of Inspection:4128197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nla
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: nla
Capacity: nta gallons
Design flow: nfa gallons/day
Alarm level: nla
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
nla
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n►a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
nla
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
nla
(revised 11/15195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Lumbert MITI Rd.Centerville
Owner: Mcleod
Date of Inspection:4128197
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
n1a
Type:
leaching pits,number: nfa
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number,length: n1a
leaching fields,number,dimensions:n1a
overflow cesspool,number:0'x8'block cesspool
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
The overflow is structurally sound and functioning properly,it was empty at the time or the Inspection.
CESSPOOLS:
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: nfa
Depth of scum layer: n1a
Dimensions of cesspool: We
Materials of construction: n1a
Indication of groundwater: n1a
inflow(cesspool must be pumped as part of inspection)
n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
n1a
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
n1a
(revised 11115195)
8
v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 Lumbert Mill Rd.Centerville
Owner: Mcleod
Date of Inspection:4128197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
l rU/1.1
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06 ,
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D At 3�
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9