The URL can be used to link to this page

Home My WebLink About0014 MASTHEAD LANE - Health (2) -- 14 MASTHEAD LANE CENTERVIL-LE A=193 - 069 i t No. 42101/3 ORA ESSELT E 10% ® O O Commonwealth of Massachusetts / 06-9 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Masthead Ln C Property Address K1.1 Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 ;-•+• page. City/Town State Zip Code Date of Inspection t7 0 r%1 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. General Information � oZ on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 8 Johns path Company Address S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 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 proving Authority 615/17 nspector'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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1,500 Gallon septic tank as well as a concrete distribution box and 4 maximizers 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is Centerville Ma 02632 6/5/17 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 l5ins•31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown 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 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. 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•3/13 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 °M 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M ,•''y 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El Z 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No 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 278 GPD 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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 I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not provided 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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: 7/23/1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): System is vented at the roof line Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 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 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. City/Town 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El 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 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityfrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box if resent must be opened) locate on site plan): ( P P ) ( P ) Depth of liquid level above outlet invert Level and at normal level 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.): 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 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 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 Maximizers ❑ 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.): No ponding or signs of failure 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•3/13 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 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts y. Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown 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: USGS maps indicate ground water well over 12' below grade home sits high above rd Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 3, i¢ b '.�`l i�Il•' '' i ua R ✓'.'?'r., _ m th�fR " 'I' ' og > ei,%. '!� E�j ,r>S y,p�'9at"t�� __s �� .! y ✓ €�&� �'� �Et 'l�,�j� i sR>ryR y y< �✓ �. E 10 k €i ✓. �/ i s m €� � � � r � � s s i ��I's' 'fi'"ro�� 3 AE��'l ✓ 1 +Ky �r > '�, ' .r'o' i"`c �:�tY € iEtN t �.1�I• E ,\ m: zr '"� �� G :��,� z` �� ,i '� 1�i,��E�lE� � � ✓n� ' �,� R 5x' k�r� ,e`�F,� rh �s��: sX/✓ ,� t`�f c"'�`'g`` r v3�p m> �,:,� � .;.:�� l�� lE� �!'i 137€,f 3a� ,�,�.dcr�rr i y rz�l "�y�'a .'� � " �/ �� h�� ` > €�'':�� a� �✓' aI s � "' _ � (��q,E�, E4•��i3��,i au� '€y Si_ €t €�,•� � , � � � ��f, »uw�illx,'�'� � „s,,,.» ,�?�,.....,,,.�,.., ..�. •,iY�t E; � 3 � �»� j 'j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Masthead Ln Property Address Bob Stewart Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF-7RNSTABLE LOCATION �� SEWAGE # 11--31 Z ViTx;LAGE C�? R//1�lfL�' /-ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ® �/ ��5 7»�✓��9 ,SEPTIC TANK CAPACITY "//-490 // LEACHING FACILITY: (type),v fit/r4 fay-J C (size) /U 1C 30 �,)",2 NO. OF BEDROOMS .3 BUILDER O O; NE PERMIT DATE: 7-Z3 y9/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells-exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 9'a 30 bl� No. / w !! Fee r v THE COMMONWEALTH OF MASSACHugf irTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for �Dizpogal *pgtem Cow6truction Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) P Complete System ❑Individual Components Location Address or Lot No. Ow�jn�'s.�1��Address and Tel.No. Assessor's Map/Parcel 67fwr.� Installer's Name,Address,and Tel.No. (� / Designer's Name,Address�and lTel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /!10 gallons per day. Calculated daily flow 133s gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank &92� >4B1J Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7—// /K cZ7 6ewmo� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this ar f Healt _ . Signed Date Application Approved by Date `7-c PL?4'7 Application Disapproved for the fo owing reasotr Permit No._ 7 s a Date Issued -2—c-1)� ———---------------=�--��t ---- --- — -- No. ,� �••� Y— -- l7 E-'� Fee S—c) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miqual *potent Congtru ion Vertnit Permission is hereby grant d to Construct 0 )R Upgrade( Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ' Provided:Construction must be completed within three years of the date of this ermit. Date: 7 a�' Approved by �- /73 a6� NO. ��''� � jig, . m Fee L/ THE COMMONWEALTH OF MASSACHUS�ET'TS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migogar *ppgtem Con5tructiou Permit Application for a Permit to Construct( )Repair( )Upgrade(v )Abandon( ) [Complete System ❑Individual Components Location Address or Lot No. /�/ ��'S� LoQ4 /� Owner's JVame,Address and Tel.No. Assessor's Map/Parcel ? Installer's Name,Address,and Tel.No. v / Designer's Name,Address and Tel.No. BOr 7'�Dln1�i CD�s�; Type of Building: Dwelling No.of Bedrooms 4f Lot Size sq.ft. Garbage Grinder( � Other Type of Building e ,016eNo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �� gallons per day. Calculated daily flow - / gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank X%3�/ry /ODO Type of S.A.S. 3D�'lO�l'Z ice//Z�i�S Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this f Hea Signed Date 7 12,51�7 Application Approved by Date -2--;& 4 .2 Application Disapproved for the following reasons r Permit No. G ? Date Issued —d 3- �P --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance / THIS IS TO Cl�ar7a a the On site ewa ee Disposal System Constructed( )Repaired( )Upgraded(�) Abandoned( )by at I y GZ55N110e"01y11 4'' has been constructed in accordance with the provisions of-Title 5 and the for Disposal System Construction Permit No. 9 2 3 7-,2 dated 2 '-'2s'' Installer Designer The issuan e- t ' pe t shall not be construed as a guarantee that the syste_R: will function as designed. Date Li Y Inspector ��/ i ri$i -.`. ynf v; rrrYa e'�-.."' 7=� ._ z�. �`� �'*.�''-1r swr,�f icy ,: ,, :w M.�. {• } o v i NOTICE:• R C . This Form Is To Be Use d d:For the Repa>!r Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) 1• ��✓- ��' ^ hereby certit+that the application for disposal works construction permit signed by me dated �31� conc v P �� 7 errun_ the property located at l� G'S�LQGt' �l meets all of the following criteria: tv/71here are no wetlands within 00 feet of the oroeused septic syste:1: R2r2 r: no oI:Vare wens wiihin 1 J OI e � sze i2et .n _r00oS2d S2GCiC $L s�_i. b/ e obserred Groundwater mbie s i— ' :,r r eater'beiov -:`he o Lom �= r_ .�� >_ � a2 .ier? :S no 'ncrease n T_':ow _,nd.or CIan2t n '_s2 7roposea c ararces =a�esi2d __�ed. SIGNED : DATE: 7/Zc3G LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. � 6i¢ g' i{$' V' }` `: .tr `t- ..1 .�„< y��, .. .. .� ±�. �y 3 !fir 4�}>• ,�f,`�y3,�Tz�.�.d'.' ��r+�6'Z' z}�..y+w,�`rygw � �;,:' ti .. .n.�� '�.`'-w,.s�m'�,,N.'rr ,C'3ia•. y�si<g� .�.�j��.R,�.ar� `3�,� ;�'. .�' '�y. o�,k,.��'.'?'' X�`f,,,�5 c"1?. .,�,. 'fib�'wS4`��'� ��.,Y ��. r '�' f:.,y� •S.[e:a"x'e''s'�1+r'�•. '2,','� �t'!`�+3. ��1.^'.s't :�:v �r ''r>C�:,�- '""'ir� ��'x�'F`,��`"r :' � r' �';� ",sr*�� i *': w�..,�v.ea ,'r'�v�y�e,..t�; "` v.:.:J1• r�L �:.v 3. �i....;' %M.w a x... .r., :r, 7rr ir. cJ" raj t�'" �i. :" ^� .'..x ,�q .t 4 U�°-.k*�'ts:� ` ,,�,,,.,�e'.:�.,44.5N;,:,{3's;.1"�.a.�zr.. .•.r`�f#.•�"Y,-.* f.�#.' K; 'd>"'�- �i�$+ fir`;a'� .;. G'��4�; � 4 � r� i�-: 'rS �<s'g yy�j �•.� �tPs y5y��,cF:' > tsrF. �.�� < ue$ � �yx v .s:•R'.'P �.k. .. ? :`�a .aa £�t � .aen e >��'t _f.3y�.t� Y�` �„p �n�i: s �x:. ..,.s:F'�...�. _- .�, - 'c,, b a<, r.. .+ .i--` a� R �� Y -� s,• �""G, �,.... �, �t ��: *�<.S'x� 5��,.:.pu+x` v�Y?,rk"`:w.�t�t:;�'" s ,yn Opp in s � I l �� Y � i- TbWN OF BARNSTABLE _ LOCATION Al SEWAGE A4—Z- VILLAGE ASSESSOR'S MAP & LOT «3 0 6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) .NO.OF BEDROOMS J BUILDER OR OWNER Z'Z IQVL� PERMTTDATE: /D�f, COMPLIANCE DATE: f� 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 j on site or within 200 feet of leaching facility) / Feet. Edge of Wetland and aching Facility(If any wetlands exist within 300 fe of ac ' facili ty Feet Furnished by � �4 t �� Al A s 7"ti e A �^ L A Ale o lj DATE: _ 6/23/97. PROPERTY ADDRESS:14. •,asthead Lane n Centerville Ma �S 0263 On the above date, l Inspected the septic system at the above address. This system consists of the following: 1 . 1000 gallon septic tank 2'. 100-gallon precast leaching pit packed in stone Based bn my Insnectlon, I certify the following conditions: 1 . This is' a Title 5 septic system. (-1.978 code) 2 - This septic• system is in failure . Waste water . is above the inlet and outlet of septic tank and also above invert pipe of Peach._- ing pit. Present septic system must be upgrade to present code . ' 1 SIGNATURE: L '� ' Name J P Macomber Jr�_______ - Company �T . P_Macoalber &-Son'_Inc q Address _-8eac-bb-------3------ I p� 0-7 A-S SSve CentervilLe LMass__02632 o f Phone:___50Z-77.-c,333a------- '-i THIS CERTIFICATION DOES NOT CONSTFTUTE A GUARANTY OR WARRANTY • rJOS.EBPOH P. MACOMBER• & SON, INC. anks-C#sspools-LeschfleldsPump+d InstalledTown Sewer Connections 56' Centerville, MA 02632-0066 775.333a 775-bd12 ,per .\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS x DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET, BOSTON, MA 02108 617-292.5500 TRUDY COXT WILLIANI F.VELD Secretary Govemor DAVID B.STRUHS ARGEO PAUL CELLUCCI Commissioner Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 14 Masthead Lane , Centerville MAddress of Owner: Reggie Sylvia Date of Inspection6/23/97 (If different) Name of Inspector- TngPnh P_ Macomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: C Mailing Address: Rnx (PntPrvi l-- I Ma n�h32_0066 Telephone Number: 5OR 77 5—3338 CERTIFICATION STATEMENT i 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 Evaluation By the Local Approving Authority .�Fails Inspector's Signature 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 Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: d?o_ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: 00) 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 yews,, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. V The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/lwww.magnet.state.ma.us/dep Printed on Recycled Paper Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Masthead Lane , Centerville , Ma. 02632 Owner: 6Repie Sylvia. Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: AQ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: (00 Cesspool or privy is within 50 feet of a surface water p Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 00 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. 1'vU The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. L0 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) y'O,THER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Masthead Lane , Centerville , Ma. 02632 Owner: Reeg5i/97ylvia Date of Inspection: /2 D] SYSTEM FAILS: You must indicate ei;'.er "Yes" or "No" as to each of the following: "Y I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303, The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. YeS No (_/ _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. e Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ✓ _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. V� _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _✓ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. I (revised 04/25/97) Page 3 of 10 I V\ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 Masthead Lane , Centerville , Ma. 02632 Owner: RRegg. ee7sylvia Date of Inspection: 22 jj/ Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. v The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. _ All system components, "cluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _✓ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Masthead Lane, Genterville,Ma. 02632 Owner: Reggie Sylvia Date of Inspection: 6/23/97 FLOW CONDITIONS RESIDENTIAL: Design flow: 23 D g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no):_jV0 Laundry connected to system (yes or no): Seasonal use (yes or no):_LL Water meter readings, if available (last two (2) year usage (gpd): IA/_3► � 5 131 LY1) C?a 3 6T.P� Sump Pump (yes or no): — T Last date of occupancy:—L23)f 7 COMMERCIAUINDUSTRIAL: Type of establishment: YV Ja Design flow: l�gallons/day Grease trap present: (yes or no)__�2Ja Industrial Waste Holding Tank present: (yes or no)�� Non-sanitary waste discharged to the Title 5 system: (yes or no)—lJCC Water meter readings, if available:L10. Last date of occupancy: OTHER: (Describe) Q. nL Last date of occupancy: �G( J GENERAL INFORMATION PUMPING RECORDS and source of information: Sew i7Ct cm 0'r� System pumped as part of inspection: (yes or no)--Y-� If yes, volume pumped: 0 gallons �t� Reason for pumping: Se�T)Ei SCIOcy'ffl `JI �k tv mpo.0 rTtf TYPE OF SYSTEM I ✓- Septic tan k/diwiml a4eft-bex/soiI absorption system Single cesspool —T Overflow cesspool A)D Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: )S U PrIPS Od Sewage odors detected when arriving at the site: (yes or no) NO (revised 04/25/97) Pays 5 of 10 PABOXOS MA OWWW N . : Reginald Silva 778-1426 cuzwo coat: Addrm: 14 Masthead Lane rsil Twn: Centerville State: Ma zip:02632 tam" address: 14 Masthead Ln Centerville MA 02632 12/13/89 pump TO bldup 332.80 1/4/90 1/20/93 pump TO 240.00 cover 35.00 1/21/93 1129/94 p mp TO 260.00 2/8/94 lv�x97� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Masthead Lane,Centerville, Ma. 02632 Owner: Regg�e97SylVia Date of Inspection: /22jj BUILDING SEWER: (Locate on site plan) t� Depth below grade: Material of construction: _cast iron ✓40 PVC _ other (explain) Distance from private water supply well or suction line Q. Diameter ,_} tr_ Comments: (condition of joints, venting, evidence of leakage, etc.) D 1I Zntn`rY-7y CPPC- nn61T Yur) r.')rihS ('7fi '.F-y -1c1g SClS�2'f� 1S yrnrc-6 ThE-oa Y�(2u s v SEPTIC TANK:_)p('D CICA 1�OtO (locate on site plan) t1 Depth below grader Material of construction: Zconcrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance ALIL(Yes/No) Dimensions: r t r �DnCf q h Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_) Distance from top of scum to top of outlet tee or baffle: 0 Distance from bottom of scum to bottom of outlet tee or b ffle: U How dimensions were determined: 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.) < <( _r S S 11 Q ) l lro nrr� - GREASE TRAP: (locate:on site plan) Depth below grade:\ Material of construct ion:YULconcrete metal 4LTiberglass'n&Polyethylene j]lother(explain) Dimensions: YV a Scum thickness: ?VCL Distance from top of scum to top of outlet tee or baffle: w_a_ Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: —"11 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 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Masthead Lane, Centerville, Ma. 02632 Owner: Reggie Sylvia Date of Inspection: 6/23/97 TIGHT OR HOLDING TANK:_AJQ�(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:-L Material of construction: 9&concrete JE�metal Y,LtEiberglasAD,Polyethylene}'E&ther(explain) Dimensions: NCB Capacity: JUG gallons Design flow: J1)r, gallons/day Alarm level: N)G Alarm in working order _ Yes; _ No Date of previous pumping: a)C� Comments: (condition of inlet tee, condition of alarm and float witches, etc.) p aht- NOT S2C-St=V1 DISTRIBUTION BOX:-ft)o7�-- (locate on site plan) Depth of liquid level above outlet invert: YL)GL. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) OnTT- PUMP CHAMBER:-]ftj)Yl�-- (locate on site plan) Pumps in working order: (Yes or No) "A Alarms in working order (Yes or No)yl)GL Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) \err m f,e (2_ �x�7— ►� r° w (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Masthead Lane, Centerville,Ma. 02632 Owner: Reggie Sylvia Date of Inspection: 6/23/97 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: U leaching galleries, number: 0 leaching trenches, number,length: () leaching fields, number, dimensions: 0 overflow cesspool, number: O Alternative system: U Name of Technology: YO Comments: (note condition of soil, signs of hydraulic failure, level of ponding, conditi of vegetation, etc.) C' CESSPOOLS: J110ni'_— (locate on site plan) Number and configuration: YUU Depth-top of liquid to inlet invert: Depth of solids layer: YUP Depth of scum layer: yl) Dimensions of cesspool: Materials of construction: in)r0 Indication of groundwater: yy 0 inflow (cesspool must be pumped as part of inspection) �X3� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: Yu1wcf- (locate on site plan) Materials of construction: A)Gl Dimensions: Depth of solids:_ V Comments: (note condition of s)il, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Masthead Lane, Centerville, Ma. 02632 Owner: eggie sylvia Date of Inspection: 6 2j/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 0 /�/ .Ma s-rA eAe,/- L A ve (revised 04/25/97) page 9 of 10 SUBSURFACE SEWAGE DISP(..):. •.I. SYSTEM INSPECTION FORM P.— C SYSTEM INFOR:' HON (continued) Property Address: 14 Masthead Lane, Centerville, Ma. 02632 Owner: Re ie Sylvia Date of Inspection: 6/ /97 Depth to Groundwater +Feet Please indicate all the methods used to determine High Groundwatc ovation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, base ,,t sump etc.) y Determine it from local conditions i 0 Check with local Board of health Vy o Check FEMA Maps ' Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Ground,, ,r Elevation. Must be completed) (revised 04/25/97) Fag. of 10 nnn rr.-nrr-n�rrn-mr•ntrrrrnr.rsn.rr..r.:-.•sr-+-rarr:�rrrer�rn nsrtm ra�rrer.rar .rn•rrr-rr.- . .F t r- TOWN OF BtJARD OF HEALTH SWISHFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION i1 �_ �•.•-•-•T•..-•. r--..i-�-.•-r.,r..-+.•r..rrt rarer.rr•rrrTn-+-•.•t*'••.rsni arrtivr�-m.rr.cvnr r+rrmrna-n►•rcr� rsm n�mrnrsrv-rm..+•.:-,rrrr-•� .-. A -TYPL OR PRINT CLEARLY- PROPERTY. INSPECTED STREET ADDRESS 14 Masthead Lane, Centerville, Ma. 02632 ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Reggie Sylvia PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & .son, Inc. COMPANY ADDRESS Box 66 Cbnterville, Ma. 02632-0066 Strevt Town or City Stat• LIP COMPANY TELEPHONE ( 508 h175 -3338 FAX (508 ) 790 -1578 . A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at 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 : 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 r'criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have coniiucted has found that the system fails to protect the jiublic health and the environment in accordance wit), Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature v Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF 11EAL711. * If the inspection FAILED, the owner or"" 'Perator shall upgrade he ay te within one year of the date of the inspection , unless allowed ort require edm otherwise as provided in 3.10 CHR 15 . 305 . partd . doc S �G JCS �C~ Ln THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF E ONMENTAL 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 S 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. Junc 8, 1995 Acting Dircctor of the - ion of Wstcr Pollution Control