HomeMy WebLinkAbout0021 MICAH HAMLIN ROAD - Health 21 Micah Hamlin Read
Centerville
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UPC 12534
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°y 21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is
required for CENTERVILLE MA 02632
every page. Citylrown 11/30/09
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important When filling out A. General Information
When
forms on the
computer,use 1. Inspector: I
only the tab key
4
to move your D
cursor-do not OUGLAS A BROWN
use the return Name of Inspector
key. DOUGLAS A BROWN INC ;
Company Name
P.O. BOX 145
Company Address
CE-To Rwn LLE MA 02632
City/Town
State Zip Code
50&420-4534 S14297
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,life q
sewage disposal systems. I am a DEP approved system inspector pursuant to Sectioh 15.340 of"
Title 5(310 CMR 15.000).The system:
r.,.t
® Passes ❑ Conditionally Passes ❑ Fails Zi-
w s�
❑ Needs Further Evaluation by the Local Approving Authority q
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011)
11/30/09 M
w
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09108 L I�/
Title 5 Official Inspection Form:Subsurface S Disposal System Pa�1 of 1
r
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Properly Address
NORMAND R VARIEUR
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 11/30/09
every page. City/Town 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 PASSES, INSPECTION PERFORMED THROUGH TANK AND D-BOX DUE TO THE
FACT THAT THERE ARE NO OBSERVATION PORTS ON LEACH TRENCHES
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09/08
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
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PREPARED EXCLUSIVELY FOR THE PURPOSE OF OBTAINING A BUILDING PERMIT, NOT FOR ANY OTHER USE
LOCATION 21 MICAH HAMLIN ROAD PREPARED FOR:
CENTERVILLE SHORELINE POOLS
SCALE : 1" = 30 DATE : AUGUST 12, 2010
REFERENCE ASSESS. MAP 170 PCL 178
PB 386 PG. 94
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off 508-362-4541 �. '1 0.40980
fax 508 362-9880 `
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CIVIL ENGINEERS ( /1
LAND SURVEYORS
939 Main Street — YARIAIOUTHPORT, MASS. DATE REG. LAND SURVEYOR
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 11/30/09
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09=
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 21 MICAH HAMLIN RD
Properly Address
NORMAND R VARIEUR
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 11/30/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than Yz day flow
t5ins•09i08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. City/Town 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.
t5fns•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal a 8 po System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632
every page. Cdy/Town 11/30/09
State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ . Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Dis sal
9 po System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. Cltylrown State Zip Code Date of Inspection
D. system Information
Description:
ACCORDING TO ASBUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND
TWO LEACH TRENCHES. HOUSE DID HAVE A GARBAGE GRINDER THAT WAS REMOVED
SEE ATTACHED PAPER WORK
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?
❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 08-257/07-263
Detail:
HOUSE DOES HAVE AN IRRIGATION SYSTEM
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
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
x Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is
required for CENTERVILLE MA 02632
every page. Cityfrown of 09
Date
State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
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.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 GALLON
Sludge depth: TRACE HOUSE VACANT
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yr. 21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVI LLE required for MA 02632 11/30/09
every page. Cltyrrown State Zip Code
Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness TRACE HOUSE VACANT
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK LOOKS CLEAN AT THIS TIME
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•09JD8 Title 5 Official Inspection Form;Subsurface Sewage Dis
8 posal System•Page 10 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene
El 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•09M 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
y 21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632
every page. Clty/Town 11
State Zip Code Datea of of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
BOX LEVEL NO SIGNS OF LEAKAGE, D-BOX COULD USE A RISER TO BRING COVER CLOSER
TO GRADE.THERE WAS A SLIGHT LAYER OF SCUM IN THE D-BOX PROBABLY FROM THE
GARBAGE DISPOSAL
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NO OBSERVATION PORTS ON LEACH TRENCHES
t5ins•09W
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
up
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2
❑ 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.):
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•09r08 Title 5 Official Inspection Form:Subsurface Sewage Disp
osal posal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. City/Town 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•09i08 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. City/Town 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
AM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. Cltyrrown 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: 25 FT+
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:
OFF PREVIOUS INSP FROM JAMES FORD DATED 10/19/05
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•0908
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r -
Commonwealth
onwealth of
Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°< 21 MICAH HAMLIN RD
Property Address
NORMAND R VARIEUR
Owner Owner's Name
information is CENTERVILLE required for MA 02632 11/30/09
every page. Cltyrrown State Zip Code
Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 0117
11117/2005 01;11 95033855314 C& ;-:'AST DEltcs
P%(a= 0c
Page 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUII.SLMACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
$rotterty Address; 21 Aficah tlerttlla Rtlod
Centeryd1e, MA
Owner: 4,11& i'Irslttlo Ehx lea
Date of Inspections Or-rohvr 1.9.2005
SKETCH OF SEWAGE DISPOSAL SYSTF M
Provide a sketch of the sew age dislwsal system including ties to at least two pennancat reference landmarks or
benchmarks. Locate all wells within 100 feet. LoMe where public water supply enters the building.
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FROWCF 1062 alr�.GM.nn hl.4 OWL To Otrda PHONE TOLL FREP I+800225.6380.-
. STATEMENT
RICK :GREGOIRE .
PLUMBING & HEATING
1030 -Phinney's Lane bATE
CENTERVILLE, MASSAC;HUSETTS 02632
Phone 775-2047
`''r1. .,
- � 1 ---------
TERMS:
-
PLEASE DETACH AND RETURN WITH YOUR REMITTANCE:
DATE- INVOICE NUMBER/DESCRiPTSpN CHARGES CREDITS BA
LANCt'
BALANCE FORWARD. -
-71
._..._.._. __ .......... Ile
- - ..._.......
-- Z...
-" - __.-----
Of
- -- _................
RICK GREGOIRE i //
PLUMBING &.HEATING " PAY LAS CNT
IN THIS COLUMOLUMN
PRODUCT T00-2®Inc.,C WOR,L1a¢01471.To Order PHONE TOLL FREE I-Mn5.M
1
TOWN OF BAMSTABLE
LOCATION a 1 M I U4^ JA NV\11A 8� SEWAGE # 9 S' /7�
VILLAGE Ck�Te�v,l� ASSESSOR'S MAP & LOT /70'
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /5 W
Tee
LEACHING FACILITY: (type) �'\ a (size) y
NO. OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac 'ng facility) Feet
Furnished by �il S/�ty S FO/e
A.
nS
� o
1 35 y-7
6 a ,
97
TOWN OF BARNSTABLE
LOCATION./ M ICA4 �-\APACLIV M SEWAGE# 95�i '70U
VILLAGE, CCbtI`►��i'� ASSESSOR'S MAP&LOTEM-LrIft—
INSTALLER'S NAME&PHONE NO. 1-A k t ILC(-, CavJs'T-
SEPTIC TANK CAPAC= l !S'b O
LEACHING FACILITY: (type) il-i-+JC-�-A
NO.OF BEDROOMS -3
BUILDER O OWNER -bD#J 'PV(LF
PERMIT ATE: COMPLIANCE DATE: 9-1 ff-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
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
;r
� I
/ O
ASSMMRSMAP 0; / 70
N.. PARCM 70
..................... YmB/ .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................1.0WQ..........OF...... ......................................
Appliration for Uhiposal Works/Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct or Repair n Individual Sewage Disposal
System at:
............... ........ ............................
p Location-Address or.1-t o.... ...... Lr
._A ?------------------------------------------------------
Owner Address
.... ..................................................
........................... ..... .......... ............ ...... .................
Installer Address
Type of Building Size Lot....-_.1-5.114-7..Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
PL4 Other—Type of Building ............................ No. of persons___....................._... Showers Cafeteria
.< Other fixtures —-
-------------------------------------------------------------------------------------- ----------------------------------S------------------------
Design Flow........................__............gallons........... -30..gallons.
W ; .....gallons per person per day. Total daily flow..........................................
c —Liquid capacityS�
1:4 Septi' Tank - gallons Length................ Width................ Diameter-___--__-___--_- Depth.._.._..........
W Width.....�9........... Total Length...._7.74,0' A
Disposal Trench—No- -----2- .... Total leaching area......A—SL.sq. ft.
Seepage Pit No....................>-1a'm'e t e r.................... Depth below inlet.._................. Total leaching area..................sq. f t.
Z Other Distribution box Dosin tank
an
Percolation Test Results Performed by..1:.> _ ..... ... ................ Date-___-- -------
Test Pit No. I...1-.....minutes per inch Depth of Test Pit___-- ft..... Depth to ground water.......r.............
Test Pit No. 2................minutes per inch Depth of Test Pit--_____-_-____-_-- Depth to ground water........................
.....................................
0 Description of Soil........................ .0- -------( -Go.......--.
-------------
...............
Z ............... . .......................... ........24.. .......Ir U - L -
.................... .............................................................................I----------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued py b,� the board of health.
board
Signed S__>. ...... . ....... ----------- . .....
Application Approved By . ........ ........... ............
Application Disapproved for the following reasons: ............................3.........................................................-------------------------------------------
.................................................. .................................................................................................................................................... ...........................
Permit I all-
......................... ---------- Issued ----------------------------------------------------;5.......
Date
——---------—-----------
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
A 1
No................-.....« Fx$.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ ...............--.....OF..... ......................... ......_..
ApplirFafiiraa for llhip sal Works Toustrurtion rumit
Application is hereby made for a Permit to Construct ( G') or Repair ( ) an Individual Sewage Disposal
System at:
A 1
Location-Address or Lot No.
......................«.......................................................................... -•-------••••--•-•-•---------------••-----.......---........-••-•-------........................._
Owner Address
ALL`-- C ... 5.�.. 3« -----.... si±:JZ` '^�= (A"�,�1 ,
,-� •----------------- ..--
Installer Address
{� riles
Type of Building Size Lot...........:...............Sq. feet
Dwelling—No. of Bedrooms................13 ....
Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons----..--_-__________________ Showers ( ) — Cafeteria ( )
0.4 Other fixtures.-.................................................. --
-------------------- - -----
:11
W
Design Flow........................_�.................gallons per person per day. Total daily flow............................................%p...gallons.
WSeptic Tank—Liquid*capacityj..........gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No.......
....2_0......... Width..... .......... Total Length...... .... Total leaching area..... ft.
Seepage Pit No.....................,Diameter-------.{............ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (1/) Ddsing tank ( ) I J� ��
►-a !
WPercolation Test Results Performed by-'________________________________!...................-................. Date......""__...... --- -- ---•---.
,.a Test Pit No. 1---'7.=__-----minutes per inch Depth of Test Pit----- _ ..... Depth to ground water--___--"""'""""
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._______--_____--------_
P4 ......................................n.-----------------••-----. ._......--------•-------......................-..................................
O Description of Soil........................ _ _. ----------------------- ----•---------•--
r�i I •7 A l f ! I . 1 -r— �/ o A -
V r r t�.- 7
- = ..,.
............... ...........................................................•-.........._._......................__._...............•-----..............................__...._..---------------•-------
U Nature of Repairs or Alterations—Answer when applicable...___..........................................................................................
........................................................•....................................-.-.....................................-..................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ................. ' .- :.� ::. :�, � ---------
Application Approved By . ................. ........... .. .................................... ............. .. ............. .......................... ........
....
.
Dace
Application Disapproved for the following reasons- ----- --- --- ------------------- ---- ------------------------------------------------- --------------------------
—.................................------------.......................................................................----------------------------. -------------------. ... ........................................
Date
PermitNo. ................. ............ ................................ Issued .....-- ...------- -- .................... .--
Dace
THE COMMONWEALTH OF MASSACHUSETTS
�__�---- BOARD OF HEALTH
....... OF
Gertifi a e of Contyliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( )/ or Repaired ( )
r 1 tic 1��..............(n 4�`!�-v e,o(PJ
by ....................... ............---...............-------------------------------------------------- ... ---------------------------------------------------------------.............
Ins ler +�
at ..��.. .....���'1,./. D ....-- 1 ��AC; _/ 'E.� -�1�-- --- ---------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ............................................... dated ................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WFUNCTION SATISFACTORY.
DATE----- ....... ---------------------------------- Inspecto . �r -- ---------- -
r
THE COMMONWEALTH OF MASSACHUSETTS
}`BOARD OF HEALTH _
,•,�� '�1 ...OF.. 'S 1 . .ti f-�-'� 1
�} ................... �......................----• •--...._..._..
No..l.. ......... 1 FEE.............. �7.
Bispviiatl Works �aaaa #ra ilan �ernti
l le�c L r'
Permission is hereby granted.........
to Construct ( ) os Re �}'r ( ) an Individual Se T e Dispo Sys
at No. �� / � �� �t 1 Yh.�J. rF.I -•- �y�-:. . .................................................
Street
as shown on the application for Disposal Works Construction Permit N ____________ _______ Dated..........................................
__�
�(DATE..............-------- ----- u .................. U Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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