HomeMy WebLinkAbout0054 MAUREEN ROAD - Health 54 MAUREEN RD, CENTERVILLE
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UPC 12543
No. 53LOR °on•co�+�'
HASTINGS, MN
Commonwealth of Massachusetts
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara c '
Owner Owner's Name
information is
required for every Centerville ✓ MA 02632 2/3/20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information '514
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
2/3/20
Inspecto Signature Ji Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
�C—\ Commonwealth of Massachusetts
ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 54 Maureen Rd.
Property Address
Mcnamara
Owner Owners Name
information is
required for every Centerville MA 02632 2/3/20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner information is Owner's Name
required for every Centerville MA 02632 2/3/20
page. CitylTown 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. P
System will ass unless Board of Health determines in accordance with 310 CMR
Y
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
1
Commonwealth of Massachusetts
r - F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. CityrFown 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
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
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 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
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 CM 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 an of the system components pumped out in the previous two weeks?
❑ ® Y Y P P P
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
90,000 gallons used 2018, 56,000 gallons used in 2019
Sump pump? ❑ Yes ® No
Last date of occupancy: Fall 2019
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Cityrrown 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: No recent pumping per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1996 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 18
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction >10'_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
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. City town State Zip Code Date of Inspection
D. System Information (cont.)
.6. Septic Tank(locate on site plan):
Depth below grade: 12
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth:
10"
Distance from top of sludge to bottom of outlet tee or baffle '12
Scum thickness trace
>2n '
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
r: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner information is Owner's Name
required for every Centerville MA 02632 2/3/20
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 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Citylrown 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.):
No adverse conditions observed, H-10 box 2' below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owners Name
information is
required for every Centerville MA 02632 2/3/20
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:
❑ leaching galleries number:
® leaching trenches number, length: 2, 40'
❑ 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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Cityrrown 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.):
Trench was video inspected, dry at this time, piping is clean, no indication of past hydraulic 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
Commonwealth of Massachusetts
ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�o 54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Cityrrown 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
�. (o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
A%J tl ll VC DMAVIO 1 t1DLL
LOCATION SEWAGE N 24, f C-A ?
W LAGE Ca.-L4 hk ASSESSOR'S MAP&LOT, - u-4
INSTALLER'S NAME&PHONE NO. Rom- f2� n
SEPTIC TANK CAPAC1Ty Oo
LEACHING FACILITY:(type) D 1 Oe�P_(size)
NO.OF BEDROOMS. .
BuLDER oR owNER VY.Ip Aq r kxdw ,= .
PERMITDATE: -fG'9L COMPLIANCE DATE:
Separation Distance Betweep the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Fee
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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AUv
t�,D QQ
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >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:
4' seperation per 1996 compliance on file
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping, the site is at 32'msl and nearby surface water is at 2'msl
You must describe how you established the high ground water elevation:
See above
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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Maureen Rd.
Property Address
Mcnamara
Owner Owner's Name
information is
required for every Centerville MA 02632 2/3/20
page. Cityrrown 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
TOWN OF BARNSTABLE
LOCATION SEWAGE # 12,9- 1_S`h
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. tlt._B1aR.:e-C iL0Cr-rid
SEPTIC TANK CAPACITY 1,�-4d cl .
LEACHING FACELrN: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: `7 j� 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
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fir.
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppYication for Migpogal *pztem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair(C-<an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
I
Type of Building:
Dwelling No.of Bedrooms _ Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures n
Design Flow gallons per day. Calculated daily flow(/ gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil e* s k::
Nature of Repairs or Alterations(A nsxyer when applicable)- N-$V,4 L-E;7-0-D
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 Environmenta ode and o place the system in operation until a Certifi-
cate of Compliance has been' his o
71 Signed Date_
Application.Approved by -
Application Disapproved for the Wowing reasons
Permit No. �/s �1 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO TI that the On-site Sewage Disposal System installed( )or re paired/replaced( on '7
by ., � or M A M ky-r-%__,
as L vrc�riJ A K.;Trer has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth below: ( w_
I^
--------- ------------= -- �- -----_-----�_ --
No. !� � ,... Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migoal 6p.5tem Construction Permit
Permission is hereby granted to -��~ ✓ `
to construct( )repair( •-• n On-site Sewage 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.
All construction must be completed
pwithin two years of the date below.
E Date: Approved by
4
Fee
Gt THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., 9ASSACHUSETTS
f
2pplicatton for Mtzpoml *pgtem ComArurtton 30ermit
Application is hereby made for a Permit to Construct( )or Repair( On-site Sewage Disposal System at:
j Location Address or Lot No. Owner's Name,Address and Tel.No.
i
ll
aWr,e�v�J
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms x Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `�� S. '- gallons per day. Calculated daily flow gallons.
1 Plan Date-, 9 " Number of sheets - Revision Date
Title 7T.
Description of Soil s+
Nature of Repairs or Alterations(Answer when applicable).
/°-elk c e-
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 ode and no to place the system in operation until a Certifi�
cate of,Compliance has been issued b this '6 of�ealt .
p y Signed Date o `
Application Approved by
Application Disapproved for the owing reasons
Permit No. %�. - .ol-iT Date Issued
S
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
, hereby certify that the application for disposal works
construction permit signed by me dated IT—Vff ( , concerning the
property located at C' teats all ofthe
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
'K
a <
K%
SIGNED : DATE: '7 ( #T
LICENSED SEPTIC S STEM INSTALLER 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].
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14
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DATE: 5/10/95----
.�M.aureen Road
PROPERTY ADDRESS� ________
Centerville,Mass .
---------------7--------
02632
------------------------
On the above date, 1 Inspected the septic system at the above address.
This system consists of the following:
A. 6x8 block cesspool
B. 1 -1000 gallon precast leach pit.
Based on my Inspection, I certify the following conditions:
A. This is not a title five septic system
B. The sewage system is in proper working order at the present time
C. The cesspool was pumped for maintenance purpos-es. onlyt
SIGNATUR
Name: J.P.Macomber Jr._-----_
Company:J-P-Macomber & Son—Inc.
Address:_ Box 66—
Centerville.,Mass. 02632
Phone:_ 508_775_3338 ------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachfieids
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Cei,;erville, MA 02632-0066
775-3338 775-6412
7
SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM
Address of property 4Q MAUv2EcaJ PD Cam►-�T��z�lccl��i
Owner I s name MACtiamara
Date of Inspection MIA11 10) i9915
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
ystem recently or as part of this inspection.
NA
As built plans have been obtained nd examined. Note if they are not
available with N/A. ,7,-,c,, * "94(-6q�L
The facility .or dwelling was inspected for signs of sewage back-up.
✓ The site was inspected for signs of breakout.
All system components, excluding the SAS, 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 SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
Inn iSiU
C>XA L_ (
2, �D8 )vo-r ( C-
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
3 number of. bedrooms
number of current residents
�o garbage grinder, yes or no
�s laundry connected to system, yes or no
=o seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
2ES�nA-� Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
o ZGco,rzp o r u I►OG 7-?t c s f-t ass s �.
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool vu tTi-4, —7
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source
information:
of
LE R�L- -Ar F 6 r %tcx�s�
Sewage odors detected when arriving at the site, yes or no
• 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
FORM
PART B
SYSTEM INFORMATION continued � -
SEPTIC TANK: TA,►L E(D CE-5,G-PcXn�L\,L.1. �-Z'�-1,-T ." 'FL> (0 c
(locate on site plan) � �����-�N� '
depth below grade• COV&e• Gc2_A.oC-,
material of construction: K_concrete metal FRP other(explain)
dimensions:__ �k� (k
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
distance from bottom of scum� to bottom of outlet tee or baffle.
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 recommendations for re airs, etc. )
?-;=C-0 wt wtI �trvC> o ZL 9 n-)6 45 -PAP-T- ULC-7 p
ITS �!�2 NA Tu2� !� FA t LEA L�S�2'bC. �1�45 TT`10 � 6
►,jo l o F I24( 1
DISTRIBUTION BOX:
K�oN4t
(locate on site plan) .
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP CHAMBER: I�O�
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B M1
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : ►C
(locate on site plan, if ,possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
T
leachin �cha�iers
�an
ber — I �cs�� -FIC
leaching number _ t"sT-P'L_LF,r `,g 8S
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number;
Comments:
(note condition of soil,, signs of hydraulic failure, level of pondin.9,
condition of v e eta ,
g tion, recommendations for maintenance or r.e airs etc '
A?j2&yK " o f Li my t.P IA4 4 F -Pt T
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of .cesspool
materials of .construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level •of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site' plan) Ko kA .
materials of construction
dimensions
depth of solids
Comments:
(note condition -of soil, signs of hydraulic failure, - level of .ponding, `
condition of vegetation, recommendations for maintenance or repairs,etc. ) ��
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
•TC al Q A
� o
/01�
LPL-\AJc[;-4
Y
DEPTH TO GROUNDWATER
L►b depth to groundwater
method of determination or approximation:
4T- V>a7-rao-A (0 F (D 'P�E P7 7A TE)6 JkzC-) =.LYD
USrQS
dk
------------
f -
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not) '
Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
- Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
Y
Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
. . �� Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
NO within . 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well.
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 Qrganic compounds, ammonia nitrogen )and nitrate nitrogen.
- 05/16/1995 13:11 508-426-3508 C.-.O.MM. WATER DEPT PA15E 04
KEY NUMBER <6523 >
NAME <MC NAMARA, PATRICK J > B-C 1 B-C 2
B-C 3 B-C 4
STREET P 0 BOX 2233
CITY CENTERVILLE ST MA ZIP 02634-2233 REF 1 REF 2
PHONE ( ) - REF 3 REF 4
METER NO, < 6070> DATE READING CONS
STREET <MAUREEN RD NO. 40 12/31/94 54 26
CITY CEN L ST LOC 06/30/94 28 16
PHONE (508) 771-1787 12/31/93 12 40
ROUTE NUMBER 21 08/27/93 0 006/27/93 952 28
SERVICE DATE 08/26/80 06/30/93 924 11
METER DATE 08/27/93 12/31/92 913 32
CAPACITY 7 STYLE T10 06/30/92 881 27
SIZE 1 RATE SCHEDULE
KEY PIT PLASTIC
NOTE RR RIGHT SIDE ADDITIONAL CONS 0
ALTERNATE MIN 0
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART D
CERTIFICATION
Inspector : Peter Sullivan PE
Location :44 Maureen Road Centerville
Date : May 10,1995
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.
I have not found any information which indicates that the system fails to adequately
protect public health or the environment as defined in 310 CMR 15.303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of this form.
Please note the summary of recommendations as presented in this form.
V truly yours O
SJj
Peter Sullivan PE
Distribution:
Original to system owner
Buyer
Board of Heath of 64
"E R
SULLIVAH
NO. 29733 °D
11-15-2000 03:23PM CENT CST FIREDEPT y 5087902365 P.02
Fire Department retains original application and issues duplicate as Fertpf .. •,
V0W11M,01MZ41.a1Z4
TezcrixCim®nCec�e �w'.�ice6— �c�acri> 4f Ciirexerue� arz i
APPLICATION and PERMIT Fee:$25.0� �
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by,
e �S�
Tank Owner Name(please print) Phil McNamara i
Address 54 Maureen Road Centerville MA 02632
Srre•� city 5t.te u'p
I
j Company Name Advanced Env .oLmental Co.or Individual none i
r,nt pelf
Address _n, gnx 47?Y�1A7 Great Western Rd. Address
Signature(if ap g fcr 'errnit) Signature(it applying for permit)
IFCi Certified Other ` IFC1 Certified - L ? ' Other
7Tank
Location, .54 Maureen Road Centerville
Sisal Address Fr i
Capacity(gallons) SQQ Substance Last Stored # 2 fuel 1
Tank Dimensions(diamater x len(jth) 5' Ong x 6' round
i
Remarks., I?ST
Frm transporting waste -Advanced Environmental $lace i-io,# MV5083956100
--
j Hazardous waste maniie5-174
--E-?,A, ----
Approved tankdis disposal;lard .lames G. Grant Co Inc. 008
i p Tank yard#
i
Type of inert gas _ Tank yard address Wolcott St. , Readville, MA
City or Towh FDIDx Permit#
i Date of issue -Date of expiration _
Dig safe approval number. QQQ[]0324S Dicq Safe Toll Frt-Tel. Number-BM322-4844
i i
Signature 1`Title of Officer granting permit
After removal(s)send Form?=290A signed by Local Fire Dept. to UST Regulatory Compliance Unit.One Ashburton Place,
Room 1310,Boston,MA C2'08-161 a.
FP-��(rgviSEd 9r981
TOTAL P.02
ei
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