HomeMy WebLinkAbout0635 LUMBERT MILL ROAD - Health 635 Lumbert Mill Road
Centerville
A= 147-090
S M E A D
No. 2-153LOR
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TOWN OF BARNSTA 3LE
LOCATION [a :�_ /VA4�ti rl#11/ 1SSSEWAGE# .2-o 10 LPS
VILLAGE Gad ASSES OR'S MAP&PARCEL / ' 7
INSTALLER'S NAME&PHONE NO. 6P•
SEPTIC TANK CAPACITY Ova
LEACHING FACILITY: (type) y-ID &((R L 5 (size)
+� T
NO. OF BEDROOMS
OWNER KI
PERMIT DATE: u a 1 D COMPLIANCE DATE: .Z
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
3S-
Commonwealth of Massachusetts _ 0 Io `
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�C !% 635 Lumbert Mill Rd.
V
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 151 #_/61 g3
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Jim The Inspector Man
use the return Company Name
key.
P.O.Box 784
Company Address
West Yarmouth Ma. 02673
City/Town State Zip Code
508-364-4398 SI 14430
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 `����utuntu►u►�
ZN OF 1 yqs�i�,o
2. ❑ Conditionally Passes ;moo,• MICHAEL '.m
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: SEARS ;�
3. El Needs Further Evaluation by the Local Approving Authority =0: No.SI14430
4. ❑ Fails %*'�'cFRTIF�`���o*�
i,����, ►Sr'N SpG`````��
3-4-21
Inspector's Signat 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.
i
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
cam, Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
+_ �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in working order at time of inspection
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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
�n = Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
o
« � 635 Lumbert Mill Rd.
u
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Il; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is
required for every Centerville Ma. 02632 3-4-21
page. CitylTown 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
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/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 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
�v e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
+= �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage NA
9 ( Y 9 (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
,T Title 5 Official Inspection Form
�1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u � 635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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
�n Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 635 Lumbert Mill Rd.
u�
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
l
❑ 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:
10-20-10
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
�
Depth below grade: 23"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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
w Title 5 Official Inspection Form
iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
635 Lumbert Mill Rd.
u
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 _ 3-4-21
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 13"feet
Material of construction:
Z concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1000 gal
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
1
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Sludge judge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 gal tank with baffle in, tee out inlet and outlet covers 12" 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
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`CJ� 635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
page. Cityrrown 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c , Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
r, �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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 16x16 with 3 outlet pipes, cover is 18" below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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:
® leaching chambers number:
24
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
�v ,T Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is
required for every Centerville Ma. 02632 3-4-21
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 24 C4 Infulltrators in 3 rows, leaching is clean and dry with no sign of failure
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
c Commonwealth of Massachusetts
w p Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 't e 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V< 635 Lumbe_rt Mill Rd. _
Property Address
Sean Italiane _
Owner Owner's Name
information is Centerville Ma. 02632_ 3-4-21
required for every _ _
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
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
I, tiI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u-
635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is required for every Centerville Ma. 02632 3-4-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
Z. Check cellar
® Shallow wells
Estimated depth to high ground water:
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: 10-14-10
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:
No ground water per plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, ! 635 Lumbert Mill Rd.
Property Address
Sean Italiane
Owner Owner's Name
information is Centerville Ma. 02632 3-4-21
required for every ------...----------_ ------ -- ----
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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O Restricted Delivery Fee N C 2014
O (Endorsement Required)
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O Total Postage&Fees $ PS
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City State,ZIP+4 -
2 MA-. 6"3
PS Form :ir August 2006 See Revers e for Instructions
Certified Mail Provides:
■ A mailing receipt
■ A unique identifier for your mailpiece
• A record of delivery kept by the Postal Service for two years
Important Reminders:
n Certified Mail may ONLY be combined with First-Class Mails or Priority Mails.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for'
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT.Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
COMPLETE • ON DELIVERY
■ Complete items 1,2,and 3.Also complete Ae'S'ign, : •
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse X ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C.r. f pelivery.
■ Attach this card to the back of the mailpiece, _4i7
or on the front if space permits. r
D, Is delive 'address different from item 1? ❑Yes
1,. Article Addressed to: If YES,enter delivery address below: 13 No
Q 12 k e,- J i Lk- (lJ al ,
t,_e r)+ r 1J l I ( e K) A, 3: Service Type I
( t1kcertifled Mail ❑Express Mail I
0 Registered ❑Return Receipt for Merchandise
C) Z -2— ❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) 11 Yes
2. Article tvUmber ! 7 012 1010 0000 2851 3795
(Transfer from service label) I
PS Form 3811. February 200A Domestic Return Receipt +.02595-02W-1540
:.j
UNITED STATES POSTAL SERVICE r� '
First'Ciass MAR
Postage&Fees Paid
LISPS
Permit No.G-10
!I Sender: Please print your name, address, and ZIP+4 in this box °
I
a
Town of Barnstable
Health Division
200 Main Street
Hyannis;MA 02601
Town of Barnstable Barnstable
ARARNMa
Regulatory Services Department i� Cft
0.19. �' Public Health Division
RFD 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scali,Interim-Director
FAX 508-790-6304 Thomas A.McKean,CHO
April 30, 2014
Amber Cullivan TR
9 Broken Dike Way
Centerville, MA 02632
FINAL ORDER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 635 Lumbert Mill Rd. Centerville, MA was last inspected
on September 13,2010,by Ricky L. Wright, a certified septic inspector for the State of
Massachusetts. The inspection of the septic system showed that the system"Failed"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overload or
clogged SAS
The deadline for repair is over due, and the deadline sent to you 1/6/14 of 60 days has
passed. Your repair permit#2010-425 is still active, but we have not been informed that
you have completed repair of your failed system. Our records do not show a final
compliance certification. Therefore, you are ordered to show evidence of repair, or finish
repair within 60 days from the date you receive this notification.
If you are unable to complete the repair by the extended deadline, you must request a
hearing before the Board of Health. To appear before the Board of Health you need to
send a written petition requesting a hearing on the matter, within seven (7) days after the
day this order was received.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
.o
CERTIP-IED MAIL. RECEIPT
r` (Domestic Mail Only;No Insurance Coverage Provided)
s
0 For delivery information visit our website at
Im �
I ,, 1 -'A
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CO Postage $ 3A1,40
Certified Fee C3o Retum Receipt Fee AFQQ (Endorsement Required)
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pTotal Postage&Fees $ !
Sent To
ti M Cu ( ,)a v) -T�
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-----�-----------------------------------------------------
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Certified Mail Provides:
■ A mailing receipt
■ A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
•. Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables;please consider,Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.Toobt3jn'Ret&m Receipt service,please complete and attach a Return
Receipt(P§Fbrm 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicaWreturn receipt,a LISPS®postmark on your Certified Mail receipt is
required. -,,,, <
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry,
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
Town of Barnstable Barnstable
.�. D i Regulatory Services Department AFAmedcaM
�Sr� I
Public Health Division •
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scali,Interim-Director
FAX: 508-790-6304 Thomas A.McKean,CHO
March 31, 2014
Amber Cullivan TR
635 Lumbert Mill Rd.
Centerville, MA 02632 ,
FINAL ORDER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 635 Lumbert Mill Rd. Centerville, MA was last inspected
on September 13, 2010,by Ricky L. Wright, a certified septic inspector for the State of
Massachusetts. The inspection of the septic system showed that the system "Failed"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overload or
clogged SAS
The deadline for repair is over due, and the deadline sent to you 1/6/14 of 60 days has
passed. Your repair permit#2010-425 is still active,but we have not been informed that
you have completed repair of your failed system. Our records do not show a final
compliance certification. Therefore, you are ordered to show evidence of repair, or finish
repair within 60 days from the date you receive this notification.
If you are unable to complete the repair by the extended deadline, you must request a
hearing before the Board of Health. To appear before the Board of Health you need to
send a written petition requesting a hearing on the matter, within seven (7) days after the
day this order was received.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
(!:2s�McIK'ean. R.S., C --
Agent of the Board of Health
PostalServiceTM
CERTIFIED MAILM RECEIPT
(Domestic Mail Only;
ru
rq
ra I A M
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ruPostage $
Certified Fee !�
O Return Receipt Fee i�Erostm\d
O (Endorsement Required) .y Here 0
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O Total Postage&Fees $ 2jto
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--------------- - --------------------------------
City,State,ZIP
Ce.nt4Vl
PS Form :0r August 2006 See Reverse for Instructions
- 1
Certified Mail Provides:
e A mailing receipt
■ A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mails,.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted-Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT.Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
1,SENDER: COMPLETE THIS SECTION COMPLETE THIS
DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse X ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. t f Def e
■ .Attach this card to the back of the mailpiece, n C, ����, J
or on the front if space permits. k�
�� D. Is delivery address different from item 1? ElY s
1. Article Addressed to: If YES,enter delivery address below: ❑No
6 3 l-u rn -4- 11
3. Service Type i
i b 2-6, Certified Mail ElExpress Mail
3 Z ❑Registered ❑Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 7 012 1010 0000 2851 18 21 �"
(Transfer from service label)
I PS Form 3811.February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED,STATES POSTAL,SERVICE First-Gass Mail
Postage&Fees Paid
USPS
Permit No.G-10
• Sender: Please print your name,'address; and ZIP+4 in this box •
I
"
i Town of Barnstable
I Health Division ! `
I O�
200 Main Street t,
Hyannis, MA 02601 z t'
aOA I
I ` t'-k
I [ I
Tt4E T
Town of Barnstable Barnstable o
ffmd
Regulatory Services Department j"' caC j
BARNSTABM '
"9. ,0� Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
1/6/2014
Amber Cullivan TR
635 Lumbert Mill Rd.
Centerville, MA 02632
FINAL ORDER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 635 Lumbert Mill Rd. Centerville, MA was last inspected
on September 13, 2010, by Ricky L. Wright, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overload or
clogged SAS
The deadline for repair has passed. We, The Public Health Division, have not been
informed that you have completed repair of your failed system. Our records do not show
a final compliance certification. Therefore, you are ordered to show evidence of repair, or
finish repair within 60 days from the date you receive this notification.
You may request a hearing before the Board of Health, a written petition requesting a
hearing on the matter, within seven (7) days after the day this order was received.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Official Website of The Town of Barnstable - Property Lookup Page 1 of 3
Assessinq Division Property Lookup Results - 2014
367 Main Street,Hyannis,MA.02601
«BACK TO SEARCH« Print Friendly
Owner Information-Map/Block/Lot: 147/090/-Use Code:1010
i
Owner
_. Owner Name as of 111113 CULLIVAN,AMBER TR Map/Block/Lot G/S MAPS
635 LUMBERT MILL ROAD 147/090/
CENTERVILLE,MA.02632
Property Address
Co-Owner Name 635 LUMBERT MILL RD NOMINEE TRUST 635 LUMBERT MILL ROAD
Village:Centerville
Town Sewer At Address:No
GIS Zoning Value:RC
.....— .
Assessed Values 2014 Map/Block/Lot.147 1 090/-Use Code:1010
. ............ ...... _........ - -. _.__..
2014 Appraised Value 2014 Assessed Value Past Comparisons
Building Value: $117,400 $117,400 Year Total Assessed Value
Extra Features: $47,400 $47,400 2013-$290,900
Outbuildings: $4,900 $4.900 2012-$289,000
2011-$285,900
Land Value: $121,000 $121,000 2010-$285,800
2009-$316,200
2008-$354,900
2014 Totals $290,700 $290,700 2007-$353,800
....... ........................................ ............... . .......... .........
Tax Information 2014-Map/Block/Lot 147 1 090/-Use Code:1010
.........
Taxes
C.O.M.M.FD Tax(Residential) $438.96
Community Preservation Act Tax $79.54 Fiscal Year 2014 TAX RATES HERE
Town Tax(Residential) $2,651.18
$3,169.68
.........
Sales History-Map/Block/Lot.147/090/ Use Code:1010
History:
Owner: Sale Date Book/Page: Sale Price:
CULLIVAN,AMBER TR 8117/2011 C194993 $195000
US BANK NAIL ASSOC 8/5/2011 C194906 $225250
SAUNDERS,JAMES V&CHARLOTTE E6/1/1979 C78320 $0
......... ........: .........._.-._..-.._.
i Photos 147 1 090/-Use Code:1010
........... .........-- - — _
I
Sketches-Map/Block/Lot: 147/090/ Use Code 1010
... ..........
0 ..
A GAR,
�I
1
AsBuilt Card N/A
Constructions Details-Map/Block/Lot:147/090/-Use Code:1010
http://www.townofbamstable.us/Assessing/propertydisplayscreen l4.asp?ap=0&searchparc... 3/31/2014
Town of Barnstable Barnstable
Regulatory Services Department e;caC
ftv
STABLE,
Public Health Division
Ctj 039. 1b
200 Main Street, Hyannis MA 02601 2Q07
Office: 508-862-4644 Thomas F.Geiler,Director .
FAX: 508-790-6304 Thomas A.McKean,CHO
1/6/2014
Amber Cullivan TR
!635 Lumbert Mill Rd.
Centerville, MA 02632
FINAL ORDER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 635 Lumbert Mill Rd. Centerville, MA was last inspected
on September 13, 2010, by Ricky L. Wright, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following_ :
• Backup of sewage into facility or system component due to an overload or
clogged SAS
The deadline for repair has passed. We, The Public Health Division, have not been
informed that you have completed repair of your failed system. Our records do.-not show
a final compliance certification. Therefore, you are ordered to show evidence of repair, or
finish repair within 60 days from the date you receive this notification.
You may request a hearing before the Board of Health, a written petition requesting a
hearing on the matter,.within seven(7) days after the day this order was received.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF T Tr BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Health Master Detail Page 1 of 1
rN
Lagged In As: TOWN\malkusk Health Master Detail Monday,December 30 2013
Application Center Parcel Lookup Selection Items
Parcel 1 Septic Perc I Well Fuel Tank
Parcel: 147-090 Location: 635 LUMBERT MILL ROAD,CENTERVILLE Owner: CULLIVAN,AMBER TR
Septic changes have been saved.
Septic 1,10/21/2010 New Septic...
Permit number: 20104 5 Permit type:I Repair Complete system r
Issue date 10/21/2010 i Complete date
Septic tank size 1000x Type/Size of SAS quik 4 field 4 73 sf\If
Installer: Fisher Rodney D. i= Card on file r
I/A service type: Select service Innovative/Alternative Technology type: Select IA type '
..........................................
Variance date : J I Abandon complete date r®m Abandon permit number
Repair deadline date : j Repair notification date : Keyword -
Comments dro 3 beom exist �ing _ Delete Septicc
Inspection 9/13/2010 New Inspection...
Number Inspection Date Inspector Result
6269 9/13/2010 .........
j Wright,Ricky L. F(Fail)
_ _ _
The following condition(s)are occurring:
r discharge or ponding of effluent to the surface of the ground
r pumping more than 4 times during the last year NOT due to clogged or obstructed pipe
F. backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool
r static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
r any portion of the SAS,cesspool,or privy below high groundwater elevation 1
r any portion of the cesspool within a Zone 1 to a public well j
r any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis j
i Received Date Comments
I
! Delete Inspection
Save Septic Changes I F7Returr ttc Lookup
�
htt ://i.ss 12,intranet/healthlVra �e p
r/HealthMasterDetail.as x?ID=147090 i2/3
P � , 1s
Health Master Detail Page 1 of 1
I
Logged In As: TOWN\malkusk Health Master Detail Friday,May 2 2014
ApOication Center Parcel Lookup Selection Items
Parcel I Septic I Perc I Well I Fuel Tank
Parcel: 147-090 Location:635 LUMBERT MILL ROAD,CENTERVILLE Owner:CULLIVAN,AMBER TR
--.. -- -- -.._....
Septic 1 10/21/' 0 New Septic..
Permit number 2010 425 Permit type: Re air Complete system: r
Issue date : 10/21/2 110 Complete date
Septic tank size: 1000x Type/Size of SAS:jquilk 4 field 4.73 sf\lf
Installer: Fisher,Rodney D. ( Card on file. r:
I/A service type: Select service{- Innovative/Alternative Technology type: Select IA type
Variance date : j i Abandon complete date :�- Abandon permit number:
Repair deadline date:F-- {O Repair notification date : 1/16/2014 :$rx Keyword:
Comments: C elete Se tic j 3 bedroom existing D. ;. p� I
i
Inspection 9/13/2010 New Inspection...
Number Inspection Date Inspector Result
6269 9/13/2010 ......J Wright,Ricky L
The following condition(s)are occurring:
F, discharge or ponding of effluent to the surface of the ground
1 F pumping more than 4 times during the last year NOT due to clogged or obstructed pipe
i
(- backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool
r static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
j f any portion of the SAS,cesspool,or privy below high groundwater elevation
i r any portion of the cesspool within a Zone 1 to a public well
I
f-' any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis
Received Date Comments
i
r -
Delete Ins —pection
i
_— —
Save Septic Changes ( i' Return to Lookup
- ...... - .._........._... -_ ::� - — -- ------ --- -- —�
http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=147090 5/,2/2014
No.f .� U r IaJ r t Fee
- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
a PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for �Digoal &p5tem Comaruction i9ermit
Application for a Permit to Construct( ) Repair(V*1-upgrade( ) Abandon( ) ❑ Complete System Individual Components
Location Address or Lot No. � Owner's Name,
,Addressond Tel.No.
Assessor's Map/Parcel 111 Cam" —T"' 1<1 A. !",ae
Installer's Name,Address,and Te.No. Designer's Name,Address land/Tel.No.
411 ,144V fake -
Type of ilding:
Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building / No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 o gpd Design flow providedS& gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank v0 Type of S.A.S. t4G .,ZeV,
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) b
jr-
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 Environmen al Code and not place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date 4 OQ:64'0
Application Disapproved by: Date
for the following reasons
Permit No. a- 01 ��.� Date Issued 10 "1 /a
Y� q t � .4 p �' •
p t`+?s Fee
THE COMMONWEALTH,OF M'ASSACHUSETTS Entered in computer: .�-
a
PUBLIC HEALTH DIVISION - TOWN"OF BARNSTABLE, MASSACHUSETTS Yes
-ZIpprication for Mig ogal 4° gtem Cot gtructiorl Permit
0
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon.( ) ❑Complete System 01ndividual Components
Location Address or Lot No. �V�� ,�oY� /� Owner's Name,Addressand Tel.No.
Assessor's Map/Parcel Icy/
Insta
ller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
t4 J/16(4
Type of ilding:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
4 Other Type of Building (,Y/ No.of Persons Showers( ) Cafeteria( )
Other Fixtures 4
Design Flow(min.required) 3 3 O gpd Design flow provided O gpd
Plan Date Number of sheets Revision Date M
Title y)
Y Size of Septic Tank /00o i Type of S.A.S.
Description of Soil
''' Nature of Repairs or Alterations(Answer when applicable) ce p
i
Date Iasi inspected:
V
Agreement:
i 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 o place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
_ Signed tc-��. Date
Application Approved by /1 Date f U
Application Disapproved by: Date
for the following reasons
4 � •
Permit No. Date Issued J U
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
i
THIS IS TO CERTIFY,that t e On site Sewage Disposal System Constructed ( ) Repaired ( Upgraded ( )
Abandoned( )by
at f v l4 r 7 has been constructed in accordance
with the provisionsrof Title 5 and the for Disposal System Construction Permit No. �2O/U -`^ 25,' dated Ju 2)
Installer `J� �s`i!-���, Designer
#bedrooms v Approved design ow gpd
The issuance of this permit shall no(be'con tr/u'edias a guarantee that the system J_U ctio. /as//8esigln�e°d#
Date ? ` `7 Inspector
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
Miq&gal *pgtem Conction Permit
Permission is hereby granted to Construct ( ) Repair ( � Up/grrade ( ) Abandon ( )
System located at 0 3 5-
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of thus pe ��
Date b _ 2 -/U Approved by /� h
Town of Barnstable
Regulatory Services
°s Thomas F. Geiler,Director
E^ MASS. Public Health Division
: s`0� Thomas McKean,Director
FD MA'S
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
6 - ��-1�l
Date: Sewage Permit# °�U � �� Assessor's Map/Parcel �Q Q i
Installer& Designer Certification Form
x
U �S leN
Designer: S �'�/� Installer y ,
Address: ' G�Z l(Address; � �/ } ,yCS 44
l/
OnSqpt-' GAI(C was issued a permit to install a
; .
(date) � (installer)
septic system at �1 /�/zz based on a design drawn by
(address)
/ ated
(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 b designer to follow. Stripout(if require ected and the soils
we found sati ctory. itµ OF 414S
� S,y
DAVID oyG�
� D.
(Installer's(Signature) o F�No.�1211 JR N
O 01STE��
�r Z417i SANI TAR�R
�1 (Designer's Signatur V /.X (Affix Designers tamp 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.
q:\office forms\designercertitication form.doc
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Town of Barnstable P#- /30 4�
Department of Regulatory Services
a&RNerAsm • Public Health Division Date Y
>,t
i639•A�e� 200 Main Street,Hyannis MA 02601
Date Scheduled l l Time
Fee Pd.— w
f
Soil Suitability Assessment for Sewage Dis osal
Performed By:
Witnessed By: —0
LOCATION& GENERAL INFORMATION
LocationE
Owner's Name ,1
10
C% ! fIE N i�. Address3C Assessor0� p Engineer's Name
NEW CO ��
REPAIR �l Telephone# l
Land Use 3 PR- I l 4' Slopes(lcfo f t�i G1�✓7 yii.Ty S p a�(v `�-(o j S 7
Surface Stones
Distances from: OPW Water Body l2'� ft Possible Wet Area fir`12&- -2 w ry /-�UGt/�niG a ,�� ft Drinking Water Well ft
r=Gvwt Rl G /lv�v� Z/Q 2
Drainage Way ft Property Line
fY.�/i✓��t/d /°v.v� It Other_ Nf2 ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands(n proximity to holes)
S E P 2 4 RECD
x M
IX
\X
M � 1
J
f ,•�, � _
Parent material(geologic) `�(2 �t/�"""C 4(ufl3(\S�[•f/� Depth to Bedrock A<�--
'!pth to Groundwater. Standing Water in Hole: 'NIA— Weeping from Pit Face AIIA
stimated Seasonal High Groundwater
Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE
Depth Obsery nding in obs.hole: in, Depth II mottles:Depth to weeping fro a of obs.hole: In, Groundwater tment ln,
Index Well# Reading Date: Index Well level ft.
Add.faetar ��ep_ rtaundwpterlevel „
PERCOLATION TEST bate t� lnt Tnte-AtAVr FDh
n yy
2.
Time at 9"
re
Time at 6"
Start Pre-soak Time @ `
--- - Time(9"-611)
End Pre-soak p 9
Rate MinJlnch ryl 4
Site Suitability Assessment: Site Passed Site Failed:
Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation' test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one (1) week prior to beginning.
Q:\SEPTICIPERCFO RM.DOC
J
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency,%Gravel)
42'l- 1321' CZ 00:�Iv'se 5;4 d 215-7 ¢
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling ,(Structure,Stones,Boulders.
Consisten % ravel
4`— "ter a
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Con i to c Gravel
i
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. 1
F.,od Insurance Rate Man:
Above 500 year flood boundary No— Yes
Within 500 year boundary No= Yes
Witi;in 100 year flood boundary No,— Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervi material exist in all areas observed throughout the
area proposed: for tije soil absorption system?
If not;what is the depth of naturally occurring pe ious material?
Certificatiw.i
I certify that o fl, S (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required train' a 'se an expe ' n escribed in 310 CMR 15.017.
Signature t -> Date
Q:\SiEPTlC\FERCFORM.DOC
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
Inspection results mustbe submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
/
on the computer, /(�n
use only the tab 1. Inspector:
key to move your
cursor-do not Ricky L. Wright
use-the return Name of Inspector
key. B & B Excavation, Inc. SEP 1 4 REC'D
Company Name
14 Teabegy Lane By
Company Address
Forestdale MA 02644
Cityrrown State Zip Code
508-477-0653 S14595
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
....,
0000
9/14/10
Inspector'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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
I
Y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic,tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M s 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
CGM , 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
20 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1'feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: > 20'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appears to be in good shape- no signs of leakage
Septic Tank(locate on site plan):
Depth below grade: 6"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: 52"X 5'2"X 8'6"
Sludge depth:
6"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness 8„
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle 101,
How were dimensions determined? scour stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound - however signs of backup over
outlet pipe, staining etc
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
L
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box appears to have some concrete deteration and sign of carryover and
severe signs of backup in all pipes
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection water level was 1' down from invert however there was staining above invert
pipe and signs of solids carryover and backup in pipe going to leaching due to failed S.A.S at one
time
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is
required for every Centerville MA 02632 9/13/10
page. CltylTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
eca'
0
0
3 ,
8 3:-
A y/ �
7
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
J� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: > 12'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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
i
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 635 Lumbert Mill Road
Property Address
Saunders
Owner Owner's Name
information is required for every Centerville MA 02632 9/13/10
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1035 V�4�A
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INE rW._ Town of Barnstable, :' U.S.POSTAGE>>PITNEY 130WES
Public Health Division
BABN6 ABLE.Q• 200 Main Street',/ --'. I ���-`�_•s `�
7S MASS. 0
`'.
rF0 MP'�� Hyannis;MA 02601 ZIP 02601 $ 00L�U4�A 0 j
a
0001383424 APR. 01. 2014
7012 _1010 0000 2851 3047 Y _ r
R�uRN RE��
' E'TURN "tO ENDER
UNCLAIMED
UNABLE TO FORWARD
BC.: S026€ 14.08Z90 `0269-04843-01-41 I
ig4b1(04002 fil�I;;I;III':!it�lllill�Il illlll�ll!!lalll!{►!1lt 11�8;1-a'►Itil!
I
- :
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and I Also complete A. Signature I
item 4 if Restricted Delivery is desired. X ❑.Agent
M Print your name and address on the reverse ❑Addressee)
I so that we can return the card to you. B. Received by(Printed Name) C.,Date of Delivery I
I ■ Attach this card to the back of the mailpiece, f
I or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes.
I 1. Article Addressed to: If YES,enter delivery address below: ❑No
I Co �� Lim rh (Y' r
I
rn 3. Service Type `
I ;ir_Certified_Mail 0 Express Mail
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
' I
2 runs fer froNumber
(frarrs 7 012 1010 0000 2 851 3047
I m serulce label)
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540I
tME T
Town of Barnstable Barn
Regulatory Services .Department
9�1AM
: `0�' Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scali,Interim-Director
FAX: 508-790-6304 Thomas A.McKean,CHO
March 31, 2014
Amber Cullivan TR
635 Lumbert Mill Rd.
Centerville, MA 02632
FINAL ORDER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 635 Lumbert Mill Rd. Centerville,MA was last inspected
on September 13, 2010,by Ricky L. Wright, a certified septic inspector for the State of
Massachusetts. The inspection of the septic system showed that the system "Failed"
under the guidelines of 1995 TITLE 5 (310 CMR 1.5.00) due to the following:
• Backup of sewage into facility or system component due to an overload or
clogged SAS
The deadline for repair is over due, and the deadline sent to you 1/6/14 of 60 days has
passed. Your repair permit#2010-425 is still active, but we have not been informed that
you have completed repair of your failed system. Our records do not show a final
compliance certification. Therefore, you are ordered to show evidence of repair, or finish
repair within 60 days from the date you receive this notification.
If you are unable to complete the repair by the extended deadline, you must request a
hearing before the Board of Health. To appear before the Board of Health you need to
send a written petition requesting a hearing-on the-.n.ater, ivithin seven (7) days after the
day this order was received.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
s McKean, R.S., C
Agent of the Board of Health
t '
LOCUS DATA --
CURRENT OWNER CHARLOTTE E. �P�� ��
SAUNDERS �G PQ �Q- �OF MASSgc
PLAN REFERENCE LC 37432-A �oF,QT G �J�O N o��EDWAR� yG
SHEET 3
DEED REFERENCE CTF 78320
No• �o r
ZONING DISTRICT RC 28 `� NA L ,y� { C)0
FLOOD ZONE "C" LOCUS MAP
ASSESSORS MAP 147 NOT TO SCALE: '' ASSESSORS
-PARCEL 90 - 147119001 /
STATE ZONE II NOT A ZONE it C
TOWN SALTWATER
ESTUARY PROTECTION NOT A —
LOT AREA 35,035t S.F. // o Cj
40.00' WIDE EASEMENT o I
/ S33'46'46"NV 40.00 200.00' O
SITE 8c SEWAGE •— L=44.49' _• •_
R=342:61 BENCHMARK "
REPAIR PLAN CORNER OF BULKHEAD a 33.7'
/ ELEVATION 3 1 _ ��_
#6.35 LAWN AREA r �
I
LUMBER T MILL ROAD WOODED
N / 125' /i �\
#635 rn
CEN TER VI LLE, AM O // EX►STING � � ;`� / w
/ 1000 GALLON TANK TO BEDROOM
DATE: OCTQaER 18, 2010 �/ REMAIN. EXISTING D-BO & 6� "'� -?
/ LEACHING PIT TO BE _ i3 DWELLING / ' �
ABANDONED IN ACCORD NC C, �� D'yA'#2 1-1WALKWA
APPLICANT: / o WITH TITLE 5. 199/ m /
KIRK M'acINTYRE �/ ,� ( D.T.H.#1 I L
#635 LUMQERT MILL RD. v / WOODED 1 w
CEN TER VI LLE PROPOSED S.A.S.
o o II' \ J
�� � I I w. \ i _ _ 0
i
MA 02632 I ROW 4" —
I 3 ROWS OF 8
SHEET 1 OF 2 O I I UNITS PER ROW I \ \ LAWN AREAL \ GARAGE ,�� DRJVEWAY I
PREPARED BY: �/ I ASSESSORS
147090 WOODED I �6\ — — 63.8'
EAS SURVEY, INC. �� i 12'
141 R T. 6 A _ N33'46'46"E STOCKADE FENCE
I I 1 265.00'
P. O. BOX 1729 ASSESSORS ASSESSORS 0 30 45 60
147118002 147118001
SANDWICH , M A 02563 '
0
PH. (508) 888-3619 1
GRAPHIC SCALE:
CELL (508) 527-3600 1 INCH = 30 FEET
SYSTEM DESIGN
RAISE COVERS TO WITHIN G" OF FINISH GRADE
SILL GEL, 38,15 2) OBSERVATION PORTS TO EXISTING DESIGN FLOW `
FINISH GRADE FINISH GRADE GRADE / SCREW ON CAP A, BEDROOMS AT 111 GP8/D USL GPD
ELEV. 37,1 ELEV. 35,8 FINISH GRADE
ELEV, 35,0 REQUIRED SEPTIC TANK
L VATION 36,5
wo e_ = e 6�Q GAL,
�.` TO E V OF COVER SEPTIC TANK PROVIDED s _19=_GAL,
OF N
,8
12'®Ss0,02 4 Pvc ' GSs 0,02 SIZE OF LEACHING FACILITY REQUIRED
SC 40 INV,-
INV: 5,09 34.24 10"TEE 14"TEE INV.- /INV.=
LONG T RM APPL. RATEQ 4_fjppl�sNCH
4'_61/2 " BAFFLE 20 DB7INV.=
3 ROWS OF 8, 32.0 OUTLET ' x 2,83' x 0.67SIZE OF LEACHING SYSTEM PROVIDED:
4-1 LIQUID LEVELINV.=33,57 H-10 QUIK4 INFILTRATOR jD VOF A 33.8 33.63 BED FORMATION 8.5'x32.0' a 32.9 330 _ 0.74 SF/GPD = _4LF S.F. MIN. REQ.
32.0 I rn o
�g 8 ® 4 EACH ^ ui USING 24 CHAMBERS WITH NO STONE AROUND
0 F H TIC, EXISTING 1,000 GALL 1 TANK TO REMAIN
TEST PIT #2 INFILTRATOR QUIK 4's EACH 34"x48"x12"
N 11 ELEV 25.0 NO G.WATER ENCOUNTERED u 2 4. SF / LF X (4'x24') = 453 S.F
a CONSTRUCTION NOTES: /
G�STrcRk OBSERVATION PORT 453x 0,74 G/SF = 335 GPD
SANIT RAP 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND � •
ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING
WORK ON THE SITE. SAND FILL SAND FILL SAND FILL (�I1` 335 GPD PROV > 330 GPD REQ. s 5 GPD RES.
2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE NO (GARBAGE DISPOSAL / GRINDER ALLOWED)
S I TE & SEWAGE WITM+ DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT
REPAIR PLAN V I OBTAIN SUCH DETERMINATIONPARKING
TANK FROM VEHICLES
AND
PRIATE BO AND THORITY, P 13094
3. VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING °0
MATERIALS OVER THE SEPTIC , D #
N ; , 635 S.A.S. AREA IS PROHIBITED If- 34"- - 34"- - 34"--� D.T.H. #1 ib D.T.H. #2
GENERAL NOTES: DATE: 10-14-10 DATE: 10-14-10
L UMBER T MILL ROAD 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. 8'-6 GROUND ELEV. 36.1 GROUND ELEV. 36.0
TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS
N FOR SUBSURFACE DISPOSAL OF SEWERAGE. SIDE VIEW NO GROUNDWATER NO GROUNDWATER
C E N TE R VI L L E, A M 2. AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE DATUM : A A
ACCESSIBLE WITHIN 6" OF FINISH GRADE, WITH ANY REMAINING LOAMY SAND LOAMY SAND
ACCESS PORTS BROUGHT TO WITHIN 12 OF FINISH GRADE. VERTICAL DATUM: BARNSTABLE GIS 10YR 5/2 10YR 5/2
DATE: OCTOBER 18, 2010 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE " '
CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE BENCH MARK USED: BULKHEAD CORNER B 4 B 4'
UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEY .LOAMY SAND LOAMY SAND
MUST WITHSTAND H-20 LOADING. ELEVATION 35.11
7.5YR 5/6 7.5YR 5/6
APPLICANT: 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION ELEV = 33.8 28" EJ ELEV = 34.0 24"
OF ALL UTILITIES PRIOR TO ANY EXCAVATION. INDICATES DEEP
KIRK M a c I N TYR E 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE DTH #1 $bTEST C-1 C-1
OR WITHIN 6 OF GRADE SHALL BE MORTARED IN PLACE. MED. SAND MED. SAND
#6 3 5 LU M B E R T MILL R D. 6. FINISH GRADE SHALL HAVE A MINIMUM OF 0.02 FEET PER . NO MOTTLING 10YR 6/8 42" 10YR 6/8 36"
FOOT OVER THE S.A.S. AND DISTRIBUTION BOX. NO WEEPING
CEN TER VI LLE 7. SEPTIC TANK SANITARY TEE'S SHALL BE CONSTRUCTED OF INDICATES
M A 02632 THE SCHEDULE
LOW LINE AND SHALLALL EXTEND A MINIMUM BE ON THE CENTERLINEOAND, ABOVE P-1 44" PERC TEST 44"
LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES.
SHEET 2 OF 2 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN m► 132" INDICATES ADJ. GROUNDWATER
2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT C-2 C-2
ELEVATION OF THE OUTLET PIPE. NO OBS. GROUNDWATER COARSE SAND COARSE SAND
i NO OBSERVED GROUNDWATER 2.5Y 7/4 2.5Y 7/4
PREPARED BY: 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES "
10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS DEPTH TO BOTTOM OF HOLE 13.0' ELEV = 25.1 132 ELEV =25.0 132
E A S SURVEY, INC. BAFFLE, 4 INCHES IN DIAMETER AND CONSTRUCTED OF 4" PVC
11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND (( B.O.H.
141 R T. 6 A SHALL BE SLOPED 1/4 INCH PER FOOT MIN. EXCEPT FOR THE t I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DAVE STANTON, RS
FIRST TWO FEET OUT OF THE DISTRIBUTION BOX WHICH SHALL DEPARTMENT OF ENVIRONMENTAL PROTECTION TO SOIL EVALUATOR
P. O. B 0 X 1729 BE LEVEL + CONDUCT SOIL EVALUATIONS AND THAT THE RESULTS ED. STONE
12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION OF MY SOIL EVALUATION ARE ACCURATE AND IN BACKHOE OPERATOR.
SANDWICH M A 02563 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW ACCORDANCE I j�IH 0 N5.100 THROUGH 15.107. RODNEY FISHER
AND APPROVAL. t ___ ___ _% Y QQ SOIL TYPE: L
PH. (508) 888-3619 13. MAGNETIC TAPE ON ALL COMPONENTS. `_ �U �L` /v PERC RATE: <2 MIN. PER INCH
CELL (508) 527-3600 EDWARD A STONE, CERTIFIED SOIL EVALUATOR LOADING RATE: 0_74 GAL/SF/MIN
r
Y
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