HomeMy WebLinkAbout0621 LUMBERT MILL ROAD - Health 621 LUMBERT MILL RD., CENTERVILLE
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TOWN OF BARNSTABLE
LOCATION SEWAGE#ZO ZO— 3 L4
VILLAGE Cen4er� ASSESSOR'S MAP&PARCEL Jt4'1
INSTALLER'S NAME&PHONE NO. t4r),) 01,53
SEPTIC TANK CAPACITY JOOO
LEACHING FACILITY.(type) (size) Z A R yLhi
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NO.OF BEDROOMS LA
X.
OWNER
PERMIT DATE: S-'q- 20 COMPLIANCE DATE: �Tl
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
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No Fee 'I®o �_
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
9ppliLation for Misposal 6pstem ConstrUttion. permit
Application for a Permit to Construct( ) Repair(✓) Upgrade( )�Abandon( ) El Complete System [A Individual Components
Y., 9
Location Address or Lot No. (021 Lurnber1 AM Rd. Owner's Name,Address,and Tel.No.Tar w-nc 1 a"W000k
.14a-
Assessor's Map/Parcel loot (o'll Lunn�jar} (' -M Koad
Installer's Name,Address,and Tel.No. 6' f xcmua�:o� lnc. Designer's Name,Address,and Tel.No.F lahor1-v3 4,rtu,r o""
34q Rout 130 Sandw1ch S0b•q-f7•0c.S3 P.O. 60.1 S31 HarwiO�, Mow. 0zteq,5
Type of Building:
Dwelling No.of Bedrooms Lot Size . 34 kres}� sift. Garbage Grinder(W)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
r
Design Flow(min.required) yy O gpd Design flow provided 4 1 3 gpd
Plan Date LA ' 19 20 Z o Number of sheets 2 Revision Date
Title
Size of Septic Tank Q,Y;S+kr10. ►� ppp p1. Type of S.A.S.(2) LQQch;ngN �fenc,4N s
Description of Soil Sec AIo n5
Nature of Repairs or Alterations(Answer when applicable) RM nw SAS And nt-5ov Tn g�(� �pli 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 Certificate of
Compliance has been issued by this Board of Health.
Si Date q1301 W
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. J Date Issued 57 9/cl—csb
Vi
No. l 3 Fee J eo •.-�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: q
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes V
4plication for Dispo,8at6p,stem Construction 3permit
Application for a Permit to Construct( ) Repair(V) Upgrade( 5Abandon( ) ❑Comp 9lete System Individual Components
�.
Location Address or Lot No. 611 Lumber 4 M,t I R a• Owner's Name,Address,and Tel.No. y o o m c k{o , o o rt,
Assessor's Map/Parcel (o'0 burn r Mdt Koaek CeAkewmt,
Installer's Name,Address,and Tel.No. q�x(aua!q)i 1 Ar. Designer's Name,Address,and Tel.No. 1tkhe r t.� �c n (Umpnl a
3 �1 900C 130 C�andw,ch SO&'t1f? ouz, .no. lAorwtct, M,,. ozv15*
Type of Building:
Dwelling No.of Bedrooms_ -1 Lot Size Acres;/ sq:fft. Garbage Grinder(0o)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required){U gpd Design flow provided 4"1's gpd
Plan Date -LI U Z 0 Number of sheets Revision Date
Title
Size of Septic Tank 1l1()0 rtr,t. Type ofS.A.S.U.) Leact,, 1r4et, r. p `
Description of Soil Sze ()lane
s ,
Nature of Repairs or Alterations(Answerwhenapplicable) Mitt nt(.) SAS o,ne ei-ho( -vo4,r_
�V ) '
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 Certificate of
Compliance has been issued by this Board^of Heealth�:--N
•r �{�
Signed � Date (- 30 f to
Application Approved by 1 Date
e r-
Application Disapproved by Date
for the following 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( )
Abandoned( )by G ¢,x c c. a k
at G 7,1 I.u rr,'cx c t M,++ V,as ct has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Now'Ar—,/ 3 L dated
Installer Q) fx{a,jot a f�c , Designer P1a4,.,rt n��rt+rl4nlAl
#bedrooms Ll design flow v_ 1� gpd-
The Approved
The issuance of this permit shall not be construed as a guarantee that the system will fw ct\io as designed.
Date \5'✓0 Inspector
- 7 --- ----- ------ - - - -'L -- ---- . _ _ --- -- -- ------ -- -------------------
13 _ --_----- Fee 1 C/
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(A Upgrade( ) Abandon( )
System located at 6 z I Uu mbe ri M I 1 2 rk.
and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 pl it. `r
Date , / J Approved by
Town of Barnstable
pp1HE roh Regulatory Services
v ti
Thomas F. Geiler, Director
BARNSTABLE ASS. '
MASS. ` Public Health Division
T g
1639.
iDrFOMpta Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
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Office: 508-862-4644 Fax: 508-790-6304
Date: S'•22- 20 Sewage Permit#ZOZO - laq Assessor's Map/Parcel _191)- 1118
Installer & Designer Certification Form
Designer: Flo► ,r_rA&4 CnV',C0 MCn+a_J Installer:
Q . Q E xcc a��—
Address: QO BOX 331 Address:
14 cru �..�
ga rs xc�k - -'Forc5idv-,1
On 20 Q A- (3 was issued a permit to install a
(date) (installer)
septic system at G21 Lur,,\�erA ( , %\ gcd , based on a design drawn by
(address)
1JaUC Flo.�erAq dated 6- 7—ZOZ.D
(designer)
_ I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State &.Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if requi ected and the soils
were found satisfactory. -` s�
moo`' h�r'S�CZ N qy
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" FLAHERT, jR.
( taller's Sig r ) No. 1211:
7 � NITARk -
t
(Designers Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice formsWesignercertification form.doc
FtME?�
Town of Barnstable PT# 0E"NSTZ-
°� Department of Inspectional Services
M
t ASS, E' Public Health Division
MASS
9•�
�63 1 9.°' 200 Main Street,Hyannis MA 02601
Office: 508-8624644
Date Scheduled " v C'" Time V
Soil Su'tability Assessment fo Sewa Disposal
Performed By: Witnessed By: �
LOC TION& GENERAL INFORMATION
A 1
Location Address: "i I Owner's Name:
l/ Owner's Address: 'e
Assessor's Map/Parcel: ! Certified Soil Evaluators Name: �Wt 0
Certified Soil Evaluators Email:
New Construction or Repair: Certified Soil Evaluators Telephone
Land Use C Slopes(%) 0 _
J Surface Stones /
Distances from: Open Water Body /J� ft Possible Wet Area M_ft Drinking Water Well/0 ft
Drainage Way r� Property Line / ft Other ft
Parent material(geologic) G , W` Whmvl.�144 Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time`
Observation ,4 Q
Hole# Time at 9"
Depth ofPerc Time at 6"
/
Start Pre-soak Time @ : Time(9"-6")
J(0 [[�
End Pre-soak ` 0'O /
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/l)
t
Deep Observation Hole Log Hole#:
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(in) (USDA) (Munsell) (Structure,Stones,Boulders,
Consistent %Gravel
n - ILS Aj
3 - Z �S
Deep Observation Hole Log Hole#:
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(in) (USDA) (Munsell) (Structure,Stones,Boulders,
Consistent %Gravel
0 - 0 C, OLI l 3 Z lU
F6
YZI
Deep Observation Hole Log Hole#:
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(in) (USDA) (Mansell) (Structure,Stones,Boulders,
Consistent %Gravel
Deep Observation Hole Log Hole#:
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(in) (USDA) (Munsell) (Structure,Stones,Boulders,
Consistent %Gravel
Flood Insurance Rate Map:
Above 500 year flood boundary No I`-- Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturall occurring pervious material exist in all areas observed throughout the area proposed for the
soil absorption system? �
If not,what is the depth of n urally occurring pervious material?
Certification
I certify that on CI d 2 (date)I have passed the soil evaluator examination approved by the Department of
Environmental Pr to ion and that the above analysis was performed by me consistent with the required training,expertise
and experience described in 310 CMR 15.017.
Signature Date ?021'd
SKETCH: (Or you can attach a separate sheet)
(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
Alf
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TOWN OF BAnnR..NII STABLE
LOCATION Coal �+�{� M�I� Iw SEWAGE #
tU-LAGE C nry✓i IL ASSESSOR'S MAP & LOT 119-001
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACrrY /M
of
LEACHING FACU rrY: (type) 02' T.$ (size)q x(o, GX (o�
NO. OF BEDROOMS 3
BUILDER�OR OWNER PAUI R 1
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
ll � 11
Furnished by S%To i nsatCTi on .FO/C
Peck,
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Town of Barnstable Barnstable
Inspectional Services
v 9ARNb'TAOLF,
IV "`A 16 . Public Health Division
Ar�Dt"oyA 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL47015 1730 0001 4988 2040
January 17, 2019
FEDERAL NATIONAL MORTGAGE ASSOCIATION
3900 WISCONSIN AVENUE NW
WASHINGTON, DC 20016
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located 621 Lumbert Mill Road, Centerville, MA was inspected on
12/17/2018 by James D. Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS or cesspool.
You are ordered to repair or replace the septic system within one (1) year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
T o c an, R. ., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\621 Lumbert Mill Road
Centerville.doc
Town of Barnstable
• s�aivszAsi,g. •
1` �, ' Regulatory Services Department
- - Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
_ +y ❑ Discharge or ponding of effluent to the surface of the ground _
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE 1 YEAR DEADLINE CRITERIA
Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments :
a
621 Lumbert Mill Road
Property Address r
Fannie Mae ;
Owner Owner's Name -Y.
information is Centerville MA 02632 12-17-18 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.
4 U
Important:When
filling out forms A. Inspector Information ,.�
_ 2 p
on the computer, `��." JFl M E S yc
use only the tab James D.Sears a�;' m
key to move your Name of Inspector = a •-4
cursor-do not Ca ewide Enterprises
use the return Company Name c
key. 153 Commercial Street �� S TN S11.01
Company Address
Mashpee MA 02649
City/Town State Zip Code
Ram 508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that: I 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 the property 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
1-3-19
pector'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
p
oj�� V6F
1 Commonwealth of Massachusetts
Title 5 Official Inspection Form
l a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
emu,
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
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:
Failed system -pits. The system is a 1000 Gallon Tank D Box and two pit's.
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 ❑ N ❑ 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
Title 5 Official Inspection Form
<�o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
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):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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,
safety and the environment:
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
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:
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.7/28/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
El ® or clogged SAS or cesspool
® Liquid depth in 7 is less than 6" below invert or available volume is less
than X2 day flow PITS
❑ ® 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
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 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
necessary to correct the failure.
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 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
u Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
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 system is considered a significant
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
❑ ® 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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
Description:
1000 Gal. Tank D Box and two pits.
Number of current residents: 0
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2016-76,000Gals
9 ( y g (gp ))' 2017-46,000Gals
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
- -. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
u
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
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: NA
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
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:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 22"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 621 Lumbert Mill Road
V
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1'
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. Precast
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle $
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Asbuilt- Plan -Tape
Sludge Judge
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 at working level w/sign's of being over loaded in the past. Tank and cover's at 1' below
grade.
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Io
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
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.):
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
M1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.� 621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town 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.):
D Box is 18" below grade w/two line's out.Wall's are gone on box.
t51nsp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* 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: 2
❑ leaching chambers number:
❑ 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town 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.):
Leaching is two 1000 Gal. Precast pit's. Pit's are 3' below grade. Pit's are full w/solid carry over.
Pit's not leaching. Need to replace system.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
J1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. v
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
• AsBuilt Page 1 of 2
// TOWN OF BA,RrNSTABLE
LOCATION SEWAGE M
VILLAGE II-, ASSESSOR'S MAP&LOT/ 11 'ODI
INSTALLER'S NAME&PHONE NO,
SEPTIC TANK CAPACn Y10
I
LEACHING FACILrrY: (type) T.S Lx L
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMrrDATE: COMPLIANCE DATE: -J
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
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=147118001&seq=1 12/14/2018
• Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
t�s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells o
lU
Estimated depth high ground water: 15'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Auger T.H. 15' no G.W.. Bottom of pit at 9' below grade. Bottom of pit at 6' above T.H. Depth.
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
`Yc Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
621 Lumbert Mill Road
Property Address
Fannie Mae
Owner Owner's Name
information is required for every Centerville MA 02632 12-17-18
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: Explanation of estimated depth to high groundwater included
r
N0
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
oFT"E'�wtio Town of Barnstable ;`; r�" '�" ' ' �'. U.S.POSTAGE>>PiTNEveowES
Public Health Division
—m�Le' ` 200 Main Street `•
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EONo+°0 Hyannis,MA02601 _
•• ` 0ZIP 2 4ry601 �@@P OQ6.56°
V� 0000336455 APR. 05. 201.7,
7015 1730 0001 4990 2717
Iv �
i Susan Blair �:Y.,:
621 Lumbert Mill Road
Marstons Mills, MA 02648
1XIE 01, DE 1. 0004112/17 1
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■ Print your name and address on the reverse ❑Agent I
so that we can return the card to you. X ❑Addressee
{ ■ Attach this card to the'back of the mailpiece, B. Received by(Punted Name) rDate of Delivery
or on the front if space permits,,
i D:,-Is delivery address different from.item W ❑Yes
If YES-enter delivery address below' ❑No
i
Susan Blair_ i
{ 621 ,urnbert Mill Road
Marstons Mills, MA 02648
3.II I IIIIII IIII III I III I II I II I I I I III) III I II I II III El dullSSignature d ignature Restricted Delivery-. ❑Registered ice Type _EI Mail Restricted)
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O Collect on Delivery Merchandise {
__��_._� _.. .._...—.___��:__: �,•—_•-•—• O Collect on Delivery Restricted Delivery ❑Signature ConfinnationTM"
❑Insured Mail ❑Signature Confirmation {
i 7 015 1730 0001 4990 2 717 ❑Insured Mail Restricted Delivery Restricted Delivery {
(over$500) l
PS Form 3811,July 2015 PSN 7530-02-006-9053 Domestic Return Receipt t
�SMF 1p�
Town of Barnstable
EMRMAWNMgM ' Regulatory Services
039.
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Susan Blair
621 Lumbert Mill Road
Marstons Mills, MA 02648
April 4, 2017
NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE BOARD OF
HEALTH REGULATIONS,NUISANCE CONTROL REGULATION NO. 1
The property owned by you located at 621 Lumbert Mill Road, Marstons Mills MA was
inspected on March 31, 2017 by Timothy B. O'Connell, R.S., Health Inspector, because
of a complaint from Barnstable Police Department.
The following violations of the Town of Barnstable Board of Health Regulations, Chapter
54 Building and Premises Maintenance were observed:
§54-2. Building and Premises Maintenance. Observed large amount of debris;
plumbing pipes, old broken windows; old metal cabinets; buckets; plastic containers and
brush stored at said property. Along with other assorted trash and garbage. All of
mentioned items not within an enclosed structure or screened from public view.
You are directed to correct the violations within fifteen (15) days of receipt of this
order letter by either moving items into enclosed structure or removing them from
property.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Please be advised that failure to comply with an order could result in a fine of$100.00. Each
day's failure to comply with an order shall constitute a separate violation.
PER ORKtA OF THE YOA OF HEALTH
om"a'
R.Sirecalth
Town of Barnstable
CERTIFIED MAIL: 7015 1730 0001 4990 2717
Q:Health/orderletters/refuse/621 lumbert mill rd 4-4-17doc
�V1 oFsr�t��
' Town of Barnstable
RAJMSrAASS. Regulatory Services
1639.
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Susan Blair
621 Lumbert Mill Road
Marstons Mills, MA 02648
April 4, 2017
NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE BOARD OF
HEALTH REGULATIONS,NUISANCE CONTROL REGULATION NO. 1
The property owned by you located at 621 Lurribert Mill Road, Marstons Mills MA was
inspected on March 31, 2017 by Timothy B. O'Connell, R.S., Health Inspector, because
of a complaint from Barnstable Police Department.
The following violations of the Town of Barnstable Board of Health Regulations, Chapter
54 Building and Premises Maintenance were observed:
.54-2. BuildinLy and Premises Maintenance. Observed large amount of debris;
plumbing pipes, old broken windows; old metal cabinets; buckets; plastic containers and
brush stored at said property. Along with other assorted trash and garbage. All of
mentioned items not within an enclosed structure or screened from public view.
You are directed to correct the violations within fifteen (15) days of receipt of this
order letter by either moving items into enclosed structure or removing them from
property.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days.after the date the order is served.
Please.be advised that failure to comply with an order could.result in a fine of$100.00.. Each
day's failure to comply with an order shall constitute a"separate violation.
PER OR
OF THE YOARAOF HEALTH
omas A. McKean, R.S.
irector of Public Health
Town of Barnstable
CERTIFIED MAIL: 7015 1730 0001 4990 2717
Q:Health/orderletters/refuse/621 lumbert mill rd 44-17doc
,t ►Citizen Web Request Page 1 of 3
17
12I e^r 1�}G�s� C/ wre 5 f
r v}Et tlit�SP,i[9LE r ,
Logged In As. Citizen Request Management �Vednesday,March 292017
TOWN\oconnelt
Route o Users Search Re ig,iests Create Re nests
Request Information
Request ID: 58676 Created: 3/28/2017 9:27:18 AM
Status: Assigned To Staff Assigned To: O'Connell,Timothy
Health Office
Chapter 54-3 : Outdoor Storage
Anonymous: No Request Category: Chapter 54-5 : Rubbish and
Garbage edit
Routine work: No Estimate: No edit
Date scheduled: edit
Estimated 4/11/2017 Change Estimated Mar April 2017 May
Completion Completion Date:
Date: Sunr27
Tue Wed Thu Fri Sat
26 28 29 30 31 1
2 4 5 6 7 8-
9 11 12 13 14'15
16 18 19 20 21 22
±23L 25 26 27 28 29 2 3 112
Created By: Crocker,Sharon Priority: Medium edit
Health Office
Citation Numbers: edit
Req7etuormation
Parce Map: 000 Block: 000 Lot: 000
See email for Numbe — --- - —
attached pictures from
Neighbor stored a lot of
garbage and outdoor Email:
items stored up against
neighbor's fence which
was blocking view as
driving driveway.The
items caused a section of
fence to come down.
Hoping to have items
removed away from
fence before they try
http://issgl2/internal\vrs/WRequest.aspx?ID=58676 3/29/2017
+i,-5tzen Web Request Page 2 of 3
putting fence back in
place.
Edit Reauestor Information
Track Request Progress
Request Work History: -Internal Note History:
Entered on 3/28/2017 9:27:18 AM
by Crocker, Sharon
See your email.Will send two groups of pictures
to T.O.
System entry on 3/28/2017 9:27:19 AM:
Assigned to O'Connell,Timothy
Enter work progress: Enter internal note:
(Viewed by everybody) (Viewed internally only)
I
v�
f Spell Check Spell Check
Add document or image link:
m .. 1 Browse..
*You can also type in a folder name to see everything in the folder
Current Links:
Time worked on request: 0 ;Response time: 0
*Time entries are in hours. Examples of time entries: 1,25,0.5,0.75, 1,3.5,0.25, 0.10
* Response time: Measured from the creation date to your first actions on the request.
* Do not include nights,weekends, and holidays in response time for most departments.
*Save changes ❑ Check to notify town employee below to
review this request.
O Save changes and notify Health Office
citizen* =a
O Close request Beck,Vanessa v
O Close request and notify citizen* Brief message to reviewer:
n
*notify works if email address was gives
Update
Spell Check
Public Use: Printer Friendly Version
Internal Use: Printer Friendly Version
http://issgl2/intemalwrs/WRequest.aspx?ID=58676 3/29/2017
R ' TOWN Or BARNSTABLE `�`� `��
LOCATION/d?5/ �aA4W,2 " ,//* � I SEWAGE #
ViLLAG>✓ L2 12-b$Pi F ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type):'�`� 7� ' ksize)
NO.OF BEDROOMS
BUILDER OR OWNER i/ l/74 ! 5�
y--
PERMITDATE: oZ L�—?,bl 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) V Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 fe of leac ' g f��ility Feet
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lrnstable Assessing Search Results Page 1 of 2
r' y
1 �
Home: Departments:Assessors Division: Property Assessment Search Results
New Search �
New Interactive. Maps >>
Owner: 2006 Assessed
Values:
RITZMAN, PAUL J.&JANE F
CHURCH STREET Appraised Value Assessed.Value
Map/Parcel/Parcel Extension Building Value: $0 $0
153 /030/ Extra Features: $0 $0
Outbuildings: $0 $0
Mailing Address Land Value: $7,100 $7,100
RITZMAN, PAUL J&JANE F
Totals $7,100 $7,100
196 CHURCH ST
W BARNSTABLE,.MA. 02668
2006 REAL ESTATE Tax Information: Tax Rates:.(per$1,000 of valuation)
Community Preservation Act Tax $ 1.34 Fire District Rates Town
Barnstable-Residential $1.90 $6.31
Barnstable-Commercial $2.51 Commerck
W. Barnstable FD Tax(Residential) $ 11.36 C.O.M.M.-All Classes $1.06 $6.54
Cotuit FD All Classes $1.33 Personal P
Town Tax(Residential) $44.80 Hyannis Residential $1.61 $6.49
Hyannis-Commercial $2.50 Other Rate:
W Barnstable-Residential $1.60 Community
W Barnstable-Commercial $2.46
Total: $57.50
Construction Details
1.
Building Property Sketch Legend
u
Construction info N/A A sketch is not available for this parcel.
Land
CODE 1320 View Interactive Maps >>
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Commonweorn or massacnusem Gy
Executive Office of Environmental Affairs
Department of
Environmental Protection
Trudy Cox•
WUllam F.Weld
ate,«
/lr9•o Paul Celluccl David B. Struh5
LL Gcavmor / �fwll ffg t*
• . +fib
MAY ii��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 3 1996 W
i ca PART A - ffC1yg '
CERTIFICATION Q
Property Addreaa:621 Lumbert Mill Road Centerville Address of Owner-
Date of Inspoc4on: 4/24/96 (If different) 9
Name of Inspector. Joseph P. Macomber Jr.
Company Na:ne,Address and Telephone Number.
J.P.Macomber V Bon Inc. Box 66 Centervil'le ,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspocted the sewage disposal system at this address and that the information reportod 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
_ Fang .
Inspector's Slgnatturo: /k2 'Date: "
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 Protoction.
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:
_ZI have not found any information which indicates that the system violates any of the failure criteria as definod in 310 CMR 15.303.
Any failure criteria not evaluatod are indicated below.
BJ,S9YSTEM CONDITIONALLY PASSES:
�IJD One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes
inspection.
Indicate yeso, 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, cra:ked, structurally unsound, shows substantial infiltration or exMtration,-or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
�J by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston, Massachusetts 02108 • FAX(617) 556-1049 • Telephone (617) 292.5500
" Printed on RtgcW Pepu
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r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinuod)
prop02.tyAdare&,n 621 Lumbert Mill Road Centerville ,Mass . 02632
Owner. Kathy Chase
Date of Inspootion:4/24/96
B)SYSTEM CONDITIONALLY PASSES(continued)
Sawage backup or breakout or her static water level obaarvW in the distribution box is due to broken or obstructed pipe(,)
or dus to a broken,sattlad or uneven distribution box. The system will pans inspection If(with approval of the Board of
Health): .
broken plpe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more thaw four times aryear due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipes)are replaced
obstruction is removed
Cl 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
DiANNF:R WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTS
Cesspool or privy is within 60 feet of a surface water
�f} Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DE'TF.RMI TS THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
CO The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
AJ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 60 feet of a privats water supply w4lL
The system has a septic tank and&oil absorption system and is less than 100 feet but 60 feet or more from a private water
supply well,unless a well Rater aaalysis for coliform bacteria and volatile organic compounds indicates that the well Is free
from pollution from that facWty�;and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm.
3) OTHER
A*
• I
(revised 11103/95;
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PrwportyAddross: 621 Lumbert Mill Road Centerville,Mass . 02632
Owner. Kathy Chase
Date of Lupeotion: 4/2 4/9 6 •
D) SYSTEM FAILSr •
•
I have daterminod that the sysWm violator one or more of the following failure criteria ai dognad In 310 CUR 15.303. The basis for
this detarmination is Identified below. The Board of Hoalth should be contacted to determine what will be uacassary to correct the
failure.
Backup of"wage into facility or system component due to an overloaded or clogged SAS or oesspool.
Discharge or ponding of affluent to the surface of the tround or surface waters due to an mrloaded or clogged SAS or
compool.
AZd static liquid level in the,distribution box above outlet invert due to an overloaded or clogged SAS or coaspwL
fg� Liquid depth in oasspo4ii Iasi than 6"below invert or available volume it leas than 1/2 day flow.
Roque pumping more tlan{tunas in the last year NOT due to clogged or obstructed pipo(s).
Number of times pumpod
Amy portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
5 thin 100 foot of a surface water supply or tributary to a surface wator supply.
Any portion of a cosy 1 or privy is wi
Any portion of a or privy is within a Zone I of a public well
A ���
Azy portion of a Cesspool or yrivy is within 60 feet of a private water supply well.
t"cT"
Any portion of a eaaagcel-c+a Iij Is lass than 100 foot but groat.cr than 60 foot from a private water supply well with no
acoeptabla water quality analysis. If the well has boon analyzed to be acceptable,attach copy of wall water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
440 The rystem servos a facility with a dwign Dow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment bocauae one or more of the following conditions List:
11Q' the rystem Is within 400 fast of a surface drinking water supply
d✓b the system ia
is within 200 ft of a tributary to a surface drinking water supply
At •) the system is locatod in a nitrogen sensitive am (Interim Wellhead Protection Aroa(IWPA)or a mappod Zone II of a public
water supply well)
The owner or operator of arty such system shs_I bring the system and facility into till compliance with the Voutdwater treatment prop =
requirements of 31{ CMR 6.00 and 6.00. plocu a consult the local regional office of the Department for ftuther information.,
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Add r... 621 Lumbert Mill Road Centerville,Mass. 02632
Owner. Kathy Chase
Date of Inspectlon: 4/24/96 e
Check if the following have been done:
Pumping information was requested of the owner, occupant, and 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.
ZAs built plans have been obtained and examined. Note if they are not available with N/A
facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
2The site was inspected for signs of breakout.
All system components,wJuding the Soil Absorption System, have been located on the site.
ZThe septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baMes or
tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum.
2The size and location of the Soil Absorption System on the site has been determined based on existing information or
a prozimated by non-intrusive methods.
The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 621 Lumbert Mill Road Centerville ,Mass . 02632
Owner. Kathy Chase
Date of Inspection:4/2 4/9 6
FLOW CONDITIONS
RESIDENTIAL•
Detigm •
flow•_,ga�� �na
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):�d
Laundry connected to system(yes or no):AA
Seasonal use(yes or no):A76
Water meter readings,if available D >
J -
Last date of occupancy: ,4eV7A/y
COMMERCIAL/INDUSTRIA-
Type of establishment: A)A
Design flow:,A,H__gallons/day
Grease trap present: (yes or no)AYfi
Industrial Waste Holding Tank present: (yea or no)AJ A
Non-sanitary waste discharged to the Title 5 system: (yea or no)&R
Water meter readings, if available: AM
Last date of occupancy: I
OTHER.(Describe) F
Last date of occupancy: 1
GENERAL INFORMATION
PUMPING RECORDS and source qf information:
System pumped as part of inspection: (yes or no)__
Reason forp umpiag
TYPE OF, SYSTEM
_S Septic tank/diatributioa box/soil absorption system
sing;.cesspool
Overflow cesspool
Privy
Shared system(yea or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPRO)UMATE AGE of all components, date installed(if known)and source of information:
� J
Sewage odors detected when arriving at the site: (yea or no)4�)
(revised 11/03/95) b
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 621 Lumbert Mill Road Centerville,Mass .
Owner. Kathy Chase
Data of Inspectlon.4/24/96
SEPTIC TANIL-_E16"e'l' A) l fi�lk •
(locate on sits plan)
Depth below grader
Material of construction: concrete_metal_FRP—other(explain)
Dimensions 4' B
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle: Q__
Scum thickness: 1J
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler
s
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.)' P„mr, aan+i a +a„1. every two — reP yPar4 TnI P+. and nnt.1 et
tees are in nlace;No e_v; denrP of leakage The�.Pi tl n tank , G et.r„nt„ral l y sou
sound No repairs are needed at the nrPGPnt t Tne _-
GREASE TRAP-A/cg.
(locate on site plan)
Depth below grade: N/Q
Material of conatruction:A/Aconcrete_metal-_FRP_other(esplain)
)A
Dimensions:
scum thickness:
Distance from top of scum to top of outlet tee or bafIIe: -4
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baflles,depth of liquid level in relation to outlet invert, stnwtural integrity,
evidence of leakage,etc.)
n B uja_al'71
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 621 Lumbert Mill Road Centerville ,Mass . 02632
Owner. Kathy Chase
Date of Inspection:4/2 4/9 6
TIGHT OR HOLDING TANYUA,Q F- '
(locate on site plan) e
Depth below grads:_
Material of construction ; oncrete metal_FRP_other(e:plain)
Dimensions:. KA
Capacity: _ us
Design flow: ona/day
Alarm level:
Comments:
(conditionof inlet tee,condition of alarm and float switches,etc.)
Wa
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: yy
Comments:
level and distribution is ual,evidence of solids carryover,evidence of leakage into or out of box,etc.) o
(note-9. 13ox is not leve. •Installed
2yl pnce of solids carry over No evidence of lonlrpao implofat
No rPj)gj-r-, qrp. -needed at the PF
PUMP CHAMBEF--Ak ,/P,
(locate on site plan)
Pumps in working order:(yes or no)—d2l
Comments:
(note cory�itioa of pumpchamber,condition of pumps and appurtenances,etc.)
m. tV
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontlnuod)
ProperVAddr. 621 Lumbert Mill Road Centerville,Mass . 02632
Owner. Kathy Chase
Date of Inspection: 4/2 4/9 6
SOIL ABSORPTION SYSTEM (SAS):_k___/
(locate on site plan, it pole;excavation not required, but may be approximated by non-intrusive methods)
•
It not determined to be present,explain:
leaching pits,number. 2
leaching chambers,number 6
leaching galleries,number.�0
leaching trenches, number,length:
leaching fields, number,dimensions:
overilow cesspool, number:,
Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,stc.)
T.nnTn 'Qanrl to aan8 R. gr a y P N n Si gn4 of hydrai:1 i n f n i lima nr =0ndJng
Al vcna+a+.inn io nnrmal No reimira needed at t�ha. ppasen+. timA
CESSPOOLS:A&4*_
(locate on site plan)
Number and oonfquration:
Depth-top of liquid to inlet invert:
Depth of solids layer. A)
Depth of scum layer._ 0
Dimams; as of cesspool: 04
- - .
Materials of construction:_
Indication of groundwater: Alta
inflow(owspool must be pumped as part of inspection)_ 414
Comments:(note oondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
11<�c� G'o�rJ�Ai'r�
PRIVY.
(locate on site plan)
Materials of construction: Dimensions:-
Depth of solids:_ 4))y
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.
11,Q
(revised 11/03/95)• 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddre.s: 621 Lumbert Mill Road Centerville,Mass . 02632
Owner. Kathy Chase
Date of Inspection: 4/2 4/9 6
r �
SKETCH OF SEWAGE DISPOSAL SYSTEM: •
include tie,to at least two permanent references landmarks or benchmarks
Iocate all wells within 100'
Centerville Osterville Marstons Mill
Water Co pa y
428-66 IR /
N I
• \ 1
IA--
I-C9
DEPTH TO GROUNDWATER
DePth to voundwater 6'+ feet
method of determination or approximation: No water encountered at 121 when system was repaired
bt a ing a . Plan on
of, uAai +.h
(revised 11/03/95) 9
• l6
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I ''PORN OF Ra rn St8ble BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
.� �•••�••• T••.-:: -T.r..-.r.-•rtr.T�tf•r.:rr:.:rr.--r.��•f1-.T•r^.:.^...:.�r..TS"�RTr r.�TrTiTeT.a'STT'ssriT�T�C... .T-.rlLrcT rrtr.•reirrrrsrsrrrrrrr..t-rrr•r.--:r
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 621 Lumbert Mill Road Centerville.Mass . 02632
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Kathy Chage
•n�-ac^-----^-tea
PAIN' D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P..Macomber & Son Inc.
COMPANY ADDRESS Box 66 Centerville,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( ) - QQQQ FAX (508 775 3338
te.re.ma arsa•e arevz.e�-�����__���� - -
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa'i system a
this address and that the information reported is true , accurate , and
complete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on.
site sewage disposal systems .
Check one :
XXXX XxXX System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection whidh I have conducted has found that the system fails to
Protect the public. health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature UZ z Date _4/29/96
'sue.—c��•�s-�-.� _ ....�. .�....
One copy of this rt.ification must be provided to the OWNER, the BUYER
( where applicable ) and the DOARD OF HErAL1'll.
* If the inspection FAILED, th'e owner or"operator shall upgrade • the ayatem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CHR 15 . 305 .
W
I V) �
llt 3r
I
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ' ion of Water Pollution Control
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500� If�r iv,
✓
62
Aq To 'kgTRUDY°t?OXE I
�oF'4C Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 621 Lambert Mill Road, Centerville, MA Name of Owner: Paul Ritz man
n
Address of Owner: 500 Ocean St.Apt. 33
Date of Inspection: June 19, 2000 Hyawds,MA 02601
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, 0sterville, MA 02655-0049 Map: 147
Telephone Number: (508)862-9400 Parcel: 118-001
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
Conditionally Passes
Needs Further Eval io By the Local Approving Authority
ails
Inspector's Signature: Date: June 21, 2000
The System Inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable,and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 621 Lwnberl Mill Road, Centerville, MA
Owner: Paul Ritvnan
Date of Inspection: June 19, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
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 complying septic tank as,
approved by the Board of Health.
_ ..Sewage backup or breakout or high static water level observed in the:distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will.pass inspection.if(with approval of the Board of
.Health)
broken pipe(s)are replaced
_ obstruction is removed .
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 621 Lumber Mill Road, Centerville, AM
Owner: Paul Ritvnan
Date of Inspection: June 19, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 ANY)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
- The system has a septic tank and soil absorption system(SAS)and the SAS is-within 100 feet to a surface vater 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 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
1
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 621 Lambert Mill Road, Centerville, MA
Owner: Paul Ritvnan
Date of Inspection: June 19, 2000
D. SYSTEM FAILS:
You must indicate either"Yes" or "No" as to each of the following:
_ I have determined that one or more of the following failure conditions exist as described.in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
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 'h 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.
privy is within 100 feet of a surface waters 1 or tributary to a surface water supply.
Any portion of a cesspool or p vy supply �Y
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:
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 H of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 621 Lumbert Mill Road, Centerville, MA
Owner: Paul Ritw= 1
Date of Inspection: June 19, 2000
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. (*The house was unoccupied.)
✓ _ 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 conditions 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:
✓ Existing information. For example, 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)l.
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 621 Lumbers Mill Road, Centerville, MA
Owner: Paul Mtvnan
Date of Inspection: June 19, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
Total DESIGN flow n/a
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no):No laundry; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two year's usage(gpd): 1999-63.000 jeals.: 1998-21,000 gals.
Sump Pump(yes or no): n/a
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: apd(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped on April 25, 1996-per treatment plant.
System pumped as part of inspection(yes or.no): No
If yes,volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: Unknown
-.. ..,.. (y
Sewage odors detected when arrivingat the site: es or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 621 Lambert Mill Road, Centerville, 11TA
Owner: Paul Ritvnan
Date of Inspection: June 19, 2000
BUILDING SEWER: _ 4
(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: ✓
(locate on site plan)
Depth below grade: 9"
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: 1000 gal.
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness:. 0"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: Measuring stick
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 inlet tee and baffle were present. The liquid level was even with the outlet invert. There were no signs of
leakage. Scum and sludge were minimal.
GREASE TRAP: None
(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.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 621 Lambert Mill Road, Centerville, 1114
Owner: Paul Rit7man
Date of Inspection: June 19, 2000
TIGHT OR HOLDING TANK: None (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 present:
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: Even
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level. There
were no signs of solids
PUMP CHAMBER: None
(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.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 621 Lambert Mill Road, Centerville, MA
Owner: Paul Ritzinan
Date of Inspection: June 19, 2000
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible;excavation not required,location may be approximated by non=intrusive'.methods)
If not located,explain:
Type:
leaching pits, number: 1-4'x 6': 1 -6'x 6'
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,damp soil,condition of vegetation,etc.)
One pit 14'x 6)was dry. The scum line was 2'up from the bottom. The bottom to grade was 6'.
One pit(6'x 6')was dry. The scum line was 3'up from the bottom. The bottom to jerade was 9'.
There were no signs of failure.
CESSPOOLS: None
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: 1
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: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 621 Lambert Mill Road, Centerville, MA
Owner: Paul Ritzman
Date of Inspection: June 19, 2000
Map: 147
Parcel: 118-001
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
1 �a
A I I
I
Al- , — —
Aa, 3a, a
ga,- 36
A3" y�,
133- q3 3
All So
Qy- 5-3
A5- �� y
as- sa�
(Sxcp 5
yxc.
revised 9/2/98 Page 10ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 621 Lumbert Mill Road, Centerville, MA
Owner: Paul Ritzman
Date of Inspection:., June 19, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole, basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
The bottom of the pit to grade was 9'. Using the Barnstable topographic map and water contours map, the maps were showing
approximately 17' +/- to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater
adjustment for this site(SOW 253, Zone C, 5100)was 6.7'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system,the inspection and/or this report.
revised 9/2/98 Page 11of11
TOWN OF BARNSTA Br E
LOCATION (a2—k I�1�1���Yt'� SEWAGE
VILLAGE ASSESSOR'S MAP & LOT _
INSTALLER'S NAME& PHONE NO. V�l C C_ 7 Q bv4�� CC),
SEPTIC TANK CAPACITY -
1
LEACHING FACILITY:(type) iT S t 64 0 (size)—.-
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER
BUILDER OR OWNERr C_ �
DATE PERMIT ISSUED: ✓ �' �
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No _
SH��°ef S-31
f
o,yU
S�
P
r '•it
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...---...(J . .....................OF.. ..................... ...
ApplirFatiou for Bispos al Works Tonstratrtiou rrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
.......................................C�....... . :�..... ` r�� ._........
._•----•••--
L ocation-Address or Lot No.
� �-- ------------` J -----••---.....--•-------------•------------•----•-- -•- -------••------•--------•----........_--------•--•----------------........-----
Own r Address
PQ Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling=No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------•............................•--...----...---•--•••••••-•••--•••------------•-••--...•••-••••••-•••••--•-••••••---•-•-•••••---•....-••••••-•-•-
W Design Flow............................................gallons per person per day. Total daily flow............................................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................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f3� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-_---_----•_--._._.
9 -•••••......-•---• ---••-......•-••••••.... ••••••--•-•...••-••••••-•••••-..•--•-•.........•-••-•--•---•... --• .....................7......
Description of Soil..: - �`� ...... ---- --4�-� 1` /"?E A �.. ...............................
x
.................... -----------•-----•------...--•------•---------•----........__....--------...-------•--------------------•----------•------•--•-----•-------------------••• .-----.............
U Nature of Repairs or Alterations—Answer when applicable....__1_..A✓s% � .� d�dd ..!t�-..�
``` -....._. -�............•• ---------------�--------------�-- �L-----------------------------------------------------------........--------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITILE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance haste en issued by die board of health.
��, IP l �
Signed.... ------••••-- ................................
Date
Application Approved By................. --------------------------------- ------� �• �T::
Date
Application Disapproved for the following reasons:................................................................................................................
-•......................................................--.......................................................................•------------••••--•-•-----------------_- ........................
Date
Permit No.•----••• c._.....:/ Issued
'�"�"� - Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
''" ;,v
Applirttlion for 11ispos al Workfi Towitrurtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ,'an Individual Sewage Disposal
System at: /
l led c � �� Z„
....... ................•-••--•----..._,.. .....•---•--•--------.........--------•--
ocation-Address or Lot No.
...----•--•-••••_..... ..............................................
Own r Address
�. _ �d �''� '�.----------.c�..s��,�....c,_..s_--•--•
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g --•--•--•------------------- P ( ) — Cafeteria ( )
a4Other fixtures -------------------•-----------------------•----•-------------------------•--------------------------------------------------------------...--••--...
W Design Flow............................................gallons per person per day. Total daily flow----........................................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................minutes per inch Depth of Test Pit.................... Depth to ground water---------............
...
14 Test Pit No. 2................mim4tes per inch Depth of Test Pit.................•.. Depth to ground water.-----------------------
9 .-•-•---•--•----------------•••---••••--•--•-•-••-----•----•••••....._•••--
DDescription of Soil.... ..-_'_4__-:.......... �' � .........1.1........ ,t'`?, 4 .......-��.......... -----------------------------
W ----------------------------------------------------------------------------------------------------------------------------------------------------------------- --- -------------------
U Nature of Repairs or Alterations—Ans er when ap livable.__.. f_ '�_�_.__.....1,6��.a____..__. !;
--------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T LIE 5 of the, State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha en issued byAhe board of health.
Si e
Date
Application Approved By••••-••--•-__. - ` ,�L.4f-=--!..Cf..--
Date
Application Disapproved for the following reasons:------•---------------------------------------------------------------------------------------------------•••-•-
------------------------------•-•----------------------•----•----•••-•••-•-•--•-•-•-•----- ...-•----------••-----------•---•••••--...........................
Date
PermitNo......... ....................... Issued--•------•-------.....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ST' � .:.:..................OF.. h. ,'�" ; ',L-�' .
Tntifiratr laf ToutpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
jy/Cti f elfdw qi
by------.....••-••--••--••••........................................•-------------------•-----------------_---•••-•-__._----------------
Instal er
has been installed in accordance with the provisions of 1'1' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._.....� r-•3o4........... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
6YSTEM WILL FUNCT ON SATISFACTORY.
DATE.............................. _'_ U._ ....................... Inspector................
THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD OF HEALTH
%VAI
No._ '- �E ............OF... e.?..��-. ......... �..... ................................ FEE..�.C1.. --.
Disposal Vorkv Tunotrur$uan rrutit
lad .... tGr
Permission is hereby granted-----(-��-�.-.---------•--. ......................................................
to Constr c ) or Repair (,54an Individu Sewage al System
at No.......4�. ........_4_L1ri' L ... -
Street
J-
as shown on the application for Disposal Works Construction Permit No'. . -__- Dated..........................................
............................. 1 ----------------------------------------------------
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ? '
L 0 CATION SEW C E PERMIT NO.
PILLAGE
INSTA L�L/)ER'S N�.�A( ME i ADDRESS
e U I L D E R OR OWNER
/Uic
i
DATE PERMIT ISSUED
tE DATE COMPLIANCE ISSUED
b
oat U r /
�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................
........... ...OFF.........�.o.0. ....-.......---------------••-------.------.-.-.-.---...._-.--
i9arkii Tnntrnrthin thrutit
dal
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: _
System
_... ----.............
ocation-A dyes - o
Owner Address
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___.._ 5 .............. Expansion Attic ( ) Garbage Grinder ( )
---
'� Other—Type of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures .................................
Design Flow-------....................................g P P P Y Y gal s.
W allons er person per des Total daily flow____.___ _.._____...._.____....... lions.
WSeptic Tank—Liquid capacity .gallons Length................ Width................ Diameter................ Depth...............
...
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area._. _ , ft.
Seepage Pit No---_------_------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1 --_--minutes per inch Depth of Test Pit____________________ Depth to ground water.._: �0
f=, Test Pit No. 20i._minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil.......................................•... ..._ . _ �
V ....•--••••••••••••••---••••••-••••....•--•-••-•••--•...--•-•-•-•-.....••••--•-••-•••--••---•----••••-•-•--•-••-••--
W
x ••-••---------- --------••-----------------••-••••••--••••-•------------•-------•...-••-•-•--•--••••----•-••-•••---•--------------•---••-••-•-•-•--•••-••••-••••••-••-•••••••--••-••......------....•••-
V 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'IT,IL 5 of e State Sanitary Code—The undersigned further agrees not to place the system in
operatioWionlpproved
er fi of ompliance has been issued by the board of health. o //1D
PPlica Y--------- --------------(D-=----------- .���4n..
----- -
Application Disapproved for the following reasons---------------------------------•-•-----•----------------------------------------------------------------•-----
.........--•••••-•••••........••••---•••••••-•-••--••-•••.....-•--•••••••-•-•---•--•-•-•---•---••••........................•••••••••-••-••-•-•-••--•---•--••••--•••-•••••------•••--•••-•---••---•-------
Date
Permit No........ �- Issued.----�:. _ _
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.................... .................OF..........................--......_...
,gyp irtttion for Biliposttl Works Tons#rnrtion Vernfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................__._f- .......... ;. .?✓U...... Z ' z-------_.--••-•-•-••----
`-.L,ocation-Address '/
Owner /
Address
---- ........................................ ---------------------------------•----
Installer Address
V Type of Building Size Lot............................Sq. feet
1-1 Dwelling—No. of Bedrooms....._ _ ______________________-----------Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
-------------------
Design
W Flow____________________________________________gallons per person per day. Total daily flow____._.__ _._______�._____.__.____.__.g P P P Y• Y gallons.
WSeptic Tank—Liquid capacity{&"ZO_gallons Length.................Width................ Diameter---------------_ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area_._ _c -"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___...__ ._ minutes per inch Depth of Test Pit____________________ Depth to ground water.... 92�f�
(Z, Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water.
9 -•---------•----------•---•••-••-----••--- ..........................
D Description of Soil........................................... Cl� �!! 61 �,..._.�
V .._..._......•-•---••-••---•--•------------------------------•••--------...---------•••-••-------••------.....-----•-----•--••••----••-•-----•--•--•--•-•......--•--------------•-----------•------------
W
UNature 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 TITLE 5 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.
Signed
�^ ate
Application Approved<:.BY f� ,i<•-�` 7�.•rr� --...... / L;�
Application Disapproved for the following reasons________________________________________________ 74-5
___
-----------= ----•------•----•-----•------ -...---..._._
1
-•-----•.......................•-•-•--•-...--------------.._..-------•-•-----------•-------------------..._-----------------••---•-•---------------•------=-----------------------------•-•-----------•-
/ Date
Permit No---------Ls
-z Issued Haze --•z-....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF....................................._................................_..............
• ��er�ifirtt#.r of f�ont�.ittn��e
THIS IS TO CERTIFY, That the Indivi ual Sewage Disposal System constructed or Repaired ( )
---------------------------------
by
.�--� ,- ---` - ..F- �_______-•-•-----•_______________
_
Inst ler
at.................................... - � •---- T
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..........� _ -_- dated-.-------1 _ N ----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ),ONSTRUED AS A GUA A TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.DATE--•----•--•---:,...'.. _ � .---•-•-------------------------- Inspector-- -••--••-----
- _ -� .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF......................................... .............................•__.........
No.....y, t..: 1 FEE........
Dispsttl Workii Ton !ttr �..Go rrmit ,� �j
Permission is hereby granted--------- ��%f% ---••---- � ._..
e��
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No------' srn r ----,.�-= t -••----------•-•-•••-••--•--••-••---•---•---•--------
•�- -- � .�.._._�_._......_.�i.: ..._.._._-_-'•Street•-------'------------------ '
as shown on the application for Disposal Works Construction Permit No.__?'__32�_ Dated........'_� �1�1 _ _...............
DATE---- '.'��.........................--•------_.._: Board of Health
FORM 1255 A. M. SULKIN, INC.. BOSTON
f
s, r •
71
Para.
3 U/aSOrc./O Pr i;Zon,
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kA
to
r
If, nrt
t !
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ELDREDGE y
NO. 19367 m
ISTER�
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LEGEND
EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN
TWO CONTOUR --- O ---
:RtNlaHED SPOT ELEVATION
FtN1,#HEO CONTOUR. . ® L — 7D L�� 3.�.��- rL /Yl� ors h7�
,QTE:- The 'location of. any existing under ound sewerage, IN
wells, or other utilities shown on this plan is approx
Mate only .as determined from records and/or verbal IsA9 kl S T•i•)1../l.♦M ASS•
information. The contractor is responsible for the
+ :verification of the existing locations in the field. SCALE# / '- 3e�_ DATE 10.4 / 8�
'
RED GE ENGINEERING CO /N CLIENT.. W1<L.•-AS I CERTIFY THAT THE PROPOSED
,.
EaIas
RE REGISTERED J08 N0. �`� '�' ' - BUILDING SHOWN ON. THIS PLAN
` C LAND CONFORMS TO THE ZONING LAWS .
DR.BY, `_`___._.
0ER RV OF BARNSTABLE , MASS.
.. 712 MAIN STREET CH. BYE y PS ....�
f " NYANN i S, MASS.
9HEET.i_- 0F ATE RE(3. LAND SURVEYOR
F M/N•D T. jS/O
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RE . NAN-/
M/N._ GRi'4 DE, iq 24-VIAM ET.ER CONCR•FTE. COi�ER ` . r
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Q O L EYEL
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/+9/N.PlTCI'I /OOC7 G.4L: ' 1 • • . • • . • • a . WASHPO 57-CA/E
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BOX v • t $ • • .• • • 1 .•• � /4.
• • • t • •FfFECTl✓L� 1 . . 3
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• t 1 . • • • it D.n PRECAS T SE&
/5/: xis = 377 , a. . ..P O/7 OR EQUIV.. . . • •a • n
l.AtvzxT &L EVAT/ONS //3 x -o = ./13 /
INVERT AT dl!/LD/NG Sc� FT �t res+P,a��Trs z0 0
4 FT, �� FT PIi41►�. C CAE 7 LL.,d T10N,
INLET .WPr/C TANK --
OUTLET SEPTIC TANK 94•G FT. •
INLET D/STRIA&[?/OM BOY 94"'t AT. ScC7"rGfr' Cam" h GROUNO.,HI�TER T/IDZE
o�/TIETDLST7?/BUTiox BOX z Fr SEXAGE 0/S'P05A L Y..SSTEM
INLET LEACH/NIr PIT T. Tjll61lLAT/DN
LEACHIIVG f0/7'itv/MENsION A
dtALE.: �4. I'O�
DES/G/V GREYER/A &- -
NUAlQER OF DEGROO/'9S 3 DIAIAWS/ON C
t;•ARaA6.C'D/5P05AL UNIT Na_ SO/L LOG SD/L 'TEEST
TOTAC.ET!'IM�4'TED FLOyt/�G.4L.�DAY SOJL TEST /1F> SOIL •71�ST�2-
MUMQE/P OF ZOACMIN4 P/TS / f`ELL'Y. 4'+� �"ELEY.: DATE.OF S,O/•L TEST FG£8 2ts} c�s
Sjj%FL&ACHIMG PEit PIT 5 ,8539 FT. /. p'_2i RESULTS ^/TNESSED dY� Cotito,i f���srs�/
dCTTOI+�1b4CN/NG P1°R P/T 3.i $Q. ET /CAM r rC P&w coLATIOJV /lATlf# MNI�IINGH
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No.366 a No. 19367 ,a0 LDRL��EsE EAAc�./IVEWRIA Pvc
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I CERTIFY THAT THE doweUdPO
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SHOWN ON THIS PLAN la LAC,ATEq
' '.&MI T11.0— O1. RE®ISTERED
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RghtFAX,:: 10/,17/2006 11 :56 PAGE 17,1 Right FAX
Triple 1-3/4" x 11-718" VERSA-LAM®2.0 3100 SP Floor BeamI171301
BC CALL®9.3 Design Report-US 1 span I No cantilevers 10112 slope Tuesday, October 17,200611:50
Build 057
File Name: BC CALC Project
Job Name: JAMES KNIERIEM Description: FB01.
Address: Specifier. KEITH
City State,Zip:CENTERVILLE, MA Designer BRIAN BIRKINBINE
Customer. BOTELLO Company. WOOD STRUCTURES INC
Code reports ESR-1040 Misc: NO KNEEWALLS FIGURED ABOVE
1
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BU. B1'
LL 3120 Ibs LL 312D Ibs
DL 1700lbs DL 1700lbs
Total of Horizontal Design Spans=16-00-00
Load Summary uve Dead Snow Wind Roof Live
Tag Description Load Type Ref. Start End 100'/0 90;6 _ 115•A 133% 125% Trib.
1 Standard Load Unf.Area(psf) Left 00-00-00 16-00-00 30 15 13-00-00
Controls Summary value %Allowable Duration Load Case Span Location Disclosure
Pos. Moment 19281 ft4bs 60.4% 100% 1 1-Internal Completeness and accuracy of input must
End Shear 4180 Ibs 35.3% 100% 1 1 -Left be verified by anyonewhowould rely on
Total Load Defl. U317(0.605') 75.8% 1 1 output as evidence of suitability for particular
0.392" 73.6% 1 1 application.Output here based on building
Live Load Defl. U489
( ) code-accepted design properties and
Max Defl. 0.606' 60.6% - 1 1 analysis methods.Installation of BOISE
Span/Depth 16.2 n/a 1 engineeredwood products must bein
acardancewith current Installation Guide
and applicable buildng codes.To obtain
Notes
Design meets Code minimum L/240 Total load deflection criteria. Installation Guide or ask questions,please
g ( ) call(800)232-0788 before installation.
Design meets Code minimum(U360)lave load deflection criteria.
Design meets arbitrary(1")Maximum load deflection criteria. BC CALCO,BC FRAMERS,AJSTM
.Minimum bearing length for BO is 1-1/7'. ALUOISTS,BC RIM BOARD-,BCI®,Minimum bearing length for B1 is 1-UT. BOISEGLULAMTM SIMPLE FRAMING
Entered/Displayed Horizontal Span Length(s)=Clear Span+112 min.end bearing+ SYSTEM®,VERSA-LAM®,VERSA-RIM
.112 intermediate bearing PVERSA-STRANDS,VERSA-STUDS are
trademarks of Boise Wood Products,L.L.C.
Connection Diagram
i+Ib d
a
o o
a
e o o a
a minimum=2" c=7-7/8"
b minimum=3" d= 12" l f
e minimum=3"
Member has no side loads. -
Connectors are:16d Common Nails e. -
Page 1 of 1
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PROFILE Flaherty Environmental Services P o. Box 331
COVERS TO BE WATERTIGHT AND SEPTIC S Y STEM Harwich, MA 02645
r j1 m A fZKSTOP OF FOUNDATION BROUGHT TO WITHIN 6' OF FINAL GRADE (not t_ o_ sc.alel INSP. PORT W I 311 OF GRADE 774.9.,)4. 166
EL. 102.0' EL. 100.0' 2" PEASTONE OR
GEOTEXTILE EL. 100.0' CLEAN SAND `
I. FILTER FABRIC �\
VENT (IF RE(Z.�
4" CAST IRON or EQUIVALENT _ 4" SCHEDULE 40 PVC PIPE t -
MIN. PITCH 1 4" PER FOOT ''
4"SCHEDULE 40 PVC PIPE
FLAW LINE (B/st2'tobeleVol)
EL. 97.2'
15' 2.0°k 5' 1%
L. EXIST. 2'
14 EL.94.5'
EL. EXIST �EIJI•' EL.96.7' L 9 .53' 96.5' (0 005%SLOPE'
rl-2o DBOX SOIL ABSORPTION SYSTEM
B F LE DOUBLE- (2) TRENCHES 3'W X 44'L X 2'D USING 5.0'
CLEAN
D PIPE AND SURROUNDED.
y . - PERFORATE
�. :'4'''% 6"CRUSHED STONE OR WASHED " TO 1 a" STONE
—' TONE EL. 89.5'
1000 GALLON SEPTIC TANK MECHANICALLY COMPACTED BY DOUBLE-WASHED TO 1 2 S
EXISTING
(DATUM: ASSUMED) BOTTOM OF TEST HOLE EL. 89.5'
USGS ADJUSTMENT: N/A LOCATION MAP
GROUNDWATER ELEV: N/A
N TH Old oUth Rd.
Fern
LOT 70
�O 4'
LOCUS
0.34 ACRESt Q
MAP 147 LOT 118-1 a
RT.28
/ NTS
/0� ON
EXISTING
4 BR
c"'0.1' DWELLING / F , JR
EXIST. S.T. 12
ISTE�
TH— O ", 'gOITAR%
DECK e/�
NO,
TH-1 LP DATE&29/2020 REVISED:
EXIST. L.P.��
r ® 39 2' SITE AND SEWAGE PLAN FOR
B& B EXCAVATION INC-
LEGEND
.7EROME HARWOOD
6 6 6 6- GAS LINE 621 LUMBERT MILL ROAD
W W W—W WATER LINE �Q �g tt t CENTERVILLE, MA
—E 6—G 6 EXIST. ELECTRIC SCALE : 1 - 30
99 EXIST. CONTOURS
99 PROP. CONTOURS REF LCP 37432-H
PAGE 1 OF 2
UoiG "'—o.-E UNDERGROUND UTIL.
.............. ........... ................. ................
....................... ....... ........ .....
GENERAL NOTES DESIGN CALCULATIONS Flaherty Environmental Services
P. 0 . Box 331
1. ALL PRECAST COMPONENTS TO BE H-1 0 S YS TEM DE TA IL Harwich, MA 02645
RATED UNLESS OTHERWISE SPECIFIED. 774.994- 1166
NUMBER OFACTUAL BEDROOMS 4
ALL COMPONENTS WITH ANY ANTICIPATED OBS, PORT
VEHICULAR TRAFFIC TO BE H-20 RATED, GARBAGE DISPOSAL UNIT NO
/
2. THE DESIGN OF THIS SYSTEM DOES,NOT• , TOTAL ESTIMATED FLOW 3
ALLOW FOR THE USE OF A GARBAGE (110 GAL/BR/DAYX4 BR) 440 GAL./DAY
GRINDER.
3. MUNICIPAL WATER IS AVAILABLE. REQUIRED SEPTIC TANK CAPACITY 6/
4. ALL CONSTRUCTION TO CONFORM WITH 440 GPD X2= 880 GAL,
310 CMR 15.000 AND ALL OTHER
1000 GAL. (EKISTINq)
APPLICABLE LOCAL, STATE AND FEDERAL SIZE OF SEPTIC TANK
CODES AND REGULATIONS.
'4
5. INSTALLER/CONTRACTOR TO REVIEW& SOIL CLASSIFICATION 4
VERIFY ALL ELEVATIONS AND DETAILS AND
DESIGN PERCOLATION RATE <2 MIN./INCH
REPORT ANY DISCREPANCIES TO
DESIGNER PRIOR TO CONSTRUCTION OR EFFLUENT LOADING RATE .0.74 GAL.IDAYIFTI.
ASSUME ALL RESPONSIBILITY 9' MIN, OF SOIL
6. INSTALLER/CONTRACTOR IS RESPONSIBLE LEACHINGAREA 2 2# PEASTONE OR .F, ILTER FABRIC
'
FOR MAINTAINING SAFE WORK AREA, BOTTOM: (3 X44)X2= 264 FT
VERIFYING ALL UTILITIES AND NOTIFYING SIDES.,
[(2,X44)X2+(2'X3)X2]X2= 376 FT2
"DIG SAFE"(1 7888-344-7233) 72 HOURS
TOTAL = 640 FT2
3/
PRIOR TO CONSTRUCTION. X 0.74 47'47GALIDAY
7. ANY CHANGES TO OR DEVIATIONS FROM
TRENCH END VIEW
THIS PLAN MUST BE APPROVED IN
WRITING BY FLAHERTY ENVIRONMENTAL USE(2) TRENCHES OF PERFORATED PIPE SURROUNDED BY
SERVICES AND LOCAL BOARD OF HEALTH. To 12 STONE, EACH TRENCH CONFIGURED AS
2
8. FINISH COVER OVER COMPONENTS IS NOT 3'WIDE X 44'LONG AND 2'DEEP
TO EXCEED 3'PER 310 CMR 15.000 UNLESS
SHOWN PER PLAN. RESERVE LEACHING CAPACITY NIA
9. ALL ABANDONED SEPTIC SYSTEM (NTS)
COMPONENTS TO BE PUMPED DRY AND
FILLED WITH CLEAN SAND OR REMOVED
AND REPLACED WITH CLEAN SAND.
10.A LL COMPONENTS TO BE PR 0 VIDED WITH SOIL EVALUATION
WATERTIGHT ACCESS PORTS WITHIN 6 OF
FINISH GRADE. D
11.A L L SEPTIC TANKS, DISTRIBUTION BOXES 7 certify that on November 12,2002,t have passed
TEST HOLE#1 TPT#20-82 TEST HOLE 42 TPT#20-82 the examination approved by the Department of
AND PIPING TO BE INSTALLED Evaluator. David D.Flaherty Jr.,RS,REHS Evaluator. David D.Flaherty Jr.,RS,REHS
Environmental Protection and that the above analysis F H Ty J
SE#2755
SE#2755
WATERTIGHT BOH Witness: Don Desmarais,RS BOH Witness: Don Desmarais,RS has been performed by me consistant with the N 21
Date., April 29 2020 required training,wpefte,and experience described
12.NO KNOWN WETLANDS OR WELLS WITHIN Date: Apdl 29,2020
in 310 CMR 15-018(2).'
150 FEET OF PROPOSED LEACHING,
TH-I ELEV.100.0' TH-2ELEV 100.0' )NOTAIM 7h
13.THIS IS NOT A CERTIFIED PLOT PLAN AND
0'-13' OIA Ls 10YR3a 0"-ill A LS IOYR312
UNDER NO CIRCUMSTANCES IS THIS PLAN
13'-42" B Ls IOYR516 13'-42" 8 LS 10YR516
TO BE USED FOR ZONING OR BUILDING
PURPOSES.
14.LOTIS SHOWN AS ASSESSOR'S MAP 147 42"-126' C MS 2.5Y616 42-.120- C MS 25Y616 r/7
PARCEL 118-1 .
AT 58-
5. LOCUS PROPERTY'S PROPOSED SYSTEM SJrTE AND SEWAGE PLAN FOR
APPEARS NOT WITHIN AN AQUIFER 4 a & 8 EXCAVATION INC./
PROTECTION DISTRICT(ZONE IT). G.W.ELEV.N/A G.W.ELEV.N/AN/AJEROME HARWOOD
621 LUMBERT MILL ROAD
TH-I ELEV.89.5' BOTTOM TH-2 ELEV.90.0,
BOTTOM —
CENTERVZLLE, MA
PAGE 20F2 DATE:412912020
U-
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