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Home My WebLink About0040 NATHAN ROAD - Health (2) 40 NATHAN LANE, CENTERVILLE A = �llll UPC 12534 � No.2-153LOR � HASTINGS. UN Commonwealth of Massachusetts a3o-e33 � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Iy lea �M 40 Nathan Road Property Address =g Bonnie Hasse Owner Owner's Name r' information is ., Centerville MA 02632 1, 2018 February required for every _ -- — -- — -- page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information v/ fad13 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T Sullivan use the return Name of Inspector key. Ready Excavtinq r� Company Name _PO Box 89 _ _ --- -- Company Address r� r ° Forestdale -- _ MA _ 02644 --_, �t City/Town State Zip Code 508-888-6055 __ S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. i am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority February 2, 2018 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 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. ^ W 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System e-i Commonwealth of Massachusetts - Title 5 Official Inspection Form = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'' 40 Nathan Road Property Address Bonnie Hasse _ Owner Owner's Name information is Centerville MA 02632 February 1, 2018 required for every _ rY page. City/Town State Zip Code Date of Inspection B. Certification (coat.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B System Conditional) Passes: Y Y ❑ 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. i 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 'k is less than 20 years old is available. El Y N /ND (Explain below): t5ins.doc•rev.6/16 Titie 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 w 40 Nathan Road _ Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA 02632 Februa 1, 2018 required for every — —ry - page. City/Town State Zip Code Date of Inspection B. Certification (coat.) ❑ 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 isle led or replaced ❑ Y ❑ N ❑ ND (Explain below): i j l ❑ 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): 1 1, C) Further Evaluation is Required 0 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. 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: i ❑ 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.doc•rev.6116 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 ,M 40 Nathan Road Property Address Bonnie Hasse _ Owner Owner's Name information is Centerville MA 02632 February 1, 2018 required for every Y _. 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 toIa 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 SASiand 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: / k" 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. i 3. Other: J, 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 1/2.day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 40 Nathan Road _ — — Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA 02632 February 1 2018 required for 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.] ❑ F1 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 J' ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is wit in 200 feet of a tributary to a surface drinking water supply i ❑ ❑ 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Nathan Road Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA_ 02632 Februa 1 2018 required for every _ _ �_ page. CityrTown 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 GPD t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts _ v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not,for Voluntary Assessments _ 40 Nathan Road Property Address Bonnie Hasse Owner Owner's Name information is Y ,Centerville MA 02632 February 1 2018 required for every _ page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2016= 131 GPD 9 ( Y 9 (gP )) 2017= 85 GPD__ Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: - -- /t Design flow(based on 310 CMR/15.203): — J Gallons per day(gpd) Basis of design flow (seats/pe�rsons/sq.ft., etc.): Grease trap present? % ❑ Yes ❑ No i Industrial waste holding tank present? ❑ Yes ❑ No i,, Non-sanitary wasteydischarged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form: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 M 0 40 Nathan Road _ Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA 02632 February 1 2018 required for every _ Y , _ _. 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: Pumped 5 years ago: Home owner records — 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not;for Voluntary Assessments 40 Nathan Road__ Property Address -- Bonnie Hasse Owner Owner's Name information is Centerville MA 02632 February 1, 2018 _ required for every _ _ ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank and leach pit installed 1982. D-box and leach field installed 12/22/1999. Certificates of Compliance on file at Health Dew_ 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 Z 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: 14" 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: 8.6' x 4.5' x 5' 1000 gallons Sludge depth: 3 t5ins.doc•rev.6116 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 s e 40 Nathan Road _ Property Address Bonnie Hasse Owner Owner's Name information is required for every Centerville MA 02632 February 1, 2018 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 31" Scum thickness 2" at inlet, 1" at outlet — Distance from top of scum to top of outlet tee or baffle 101, Distance from bottom of scum to bottom of outlet tee or baffle 14 — How were dimensions determined? _Dip tube and 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.): Inlet and outlet concrete baffles in place. Liquid level at outlet invert. Riser on inlet bring covers within 2" of grade. Outlet 8" below grade. Light root intrusion removed during inspection. Not affecting system operation. Pumping not needed at time of inspection. Recommend maintenance pumping in 2019. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: / ❑ concrete ❑ metal ' ❑ fiberglass ❑ polyethylene ❑ other(explain): i Dimensions.- Scum thickness I 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 t.5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1= — 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Nathan Road _ Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA 02632 _ February 1, 2018 required for every — _ y 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: i ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i Dimensions: Capacity: gallons Design Flow: — gallons per day Alarm present: ❑ Yes ❑ No i 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.doc•rev.6/16 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 _ 40 Nathan Road Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA 02632 February 1, 2018 required for every _ ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): One inlet, two outlets. Leach pit outlet has speed',leveler set slightly above liquid level. Active flow going to leach field. Riser brings cover within 6"of grade. No sign of high water staining over invert to SAS. 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: _ l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Nathan Road Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA 02632 February 1, 2018 required for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6' x 4'w/stone ® leaching chambers number: 2-500 gal ea. w/4' stone ❑ leaching galleries number: — ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: — ❑ overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Camera used to inspect leach pit and chambers. Leach pit dry at time of inspection. Light staining visible. 2' below grade. Leach chamber has 3+° standing liquid at time of inspection. High water staining 1.3+2 below invert. Clean stone visible in sidewall of chamber. No sign of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration i Depth —top of liquid to inlet invert /` --- Depth of solids layer {�( --- Depth of scum layer Dimensions of cesspool Materials of construction,," -- r Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6116 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 .° 40 Nathan Road Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA. 02632 February 1, 2018 required for 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.): f f" t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.14 of 17 Commonwealth of Massachusetts -- 02 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 40 Nathan Road__ Property Address Bonnie Hasse Owner Owner's Name information is Centerville MA, 02632 February 1, 2018 required for every — page. Citylrown 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 A fa f ' I I t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts q r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not;for voluntary Assessments 40 Nathan Road _ Property Address Bonnie Hasse Owner Owner's Name information is _MA! 02632 Februa 1, 2018 required for every Centerville _ _ _ ry _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells >5 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1999 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: maps.massgLs state.ma.us/oliver.php _. You must describe how you established the high ground water elevation: Log sheet from 1999 shows ajusted ground water at elv= 27. Base of tech pit at elv= 38. Base of chambers at elv= 39. Accessed local ground water contours and topo mapping. No high ground water in area of system. -- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 40 Nathan Road Property Address Bonnie Hasse Owner Owner's Name information is required for every Centerville MA 02632 February 1, 2018 - - page. CityrFown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE G LOCATION 4/0Al d f&A II✓ L A SEWAGE # 1 q OE— 9 6 3 VILLAGE C eAl to B L L 2 ASSESSOR'S MAP & LOT _ INSTALLER'S NAME&PHONE NO. M ,�C 0 Me C R f 5 p AJ SEPTIC TANK CAPACITY lT o o ld L® LEACHING FACILITY: (type) ty L'al-Ageas (size) .-UGC AL NO.OF BEDROOMS .� BUILDER OR OWNER W ll r. ►, 1G�„� PERMTTDATE: I`�L - I6 - 7 q 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 O S / 6 0 > , ' ?` /�� AlQit) No. 7`— n'3 , Fee $ 50. 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION.- TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPlicatiou for Digiogar *p5tem Cougtruction Permit Application for a Permit to Construct(X�Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No.'4 0 Nathan Lane owner's Name,Address and Tel.No. W i 11 i a m K e r r Centerville,Mass .' 02632 32712 Westwood Loop Assessor's Map/Parcel ` 3 v 0 3 5 Leesburg , F l o r i d a 34748 Installer's Name,Address;and Tel.No., 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc . Box 66 Centervi.11e ,Mass . 02632 Box 66 Centerville ,Mass. 02632 Type of Building: Dwelling X X No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1000 + Box Type of S.A.S. Existing pit 6':xl2 ' Description of Soil Loamy sand to medium sand . Nature of Repairs or Alterations(Answer when applicable) add in g two 500 gallon leaching chambers packed in 4 ' of stone with a 3/8" stone cap . 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 issu d by this o d of Health. Signed Date 12/16/9 9 Application Approved by Date t7— 17- Application Disapproved for the following reasons Permit No. 3 Date Issued 17 TOWN OF BARNSTABLE q LOCATION 4'0 A/ d f&Ahi A SEWAGE # _1 �- VILLAGE C eA/re if V/L 1 e -ice ASSESSOR'S MAP & LOT > INSTALLER'S NAME&PHONE NO. 00 0 Al? A C t-) Af G R t 5o Al SEPTIC TANK CAPACITY /,Q Oct iT t1, o o LEACHING FACILITY: (type) . ,4'Y,6 w C/NAQRsr (size) S_00 6,44 NO.OF BEDROOMS 3 i BUILDER OR OWNER j PERMITDATE: % - - I G - Y COMPLIANCE DATE: i Separation Distance Between the: i 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 fee(of leaching facility) Feet Furnished by i i i / i f' No. ,M Fee� $ 50. 00 � THE O F MASSACHUSET Entered in computer: COMMONWEALTHT `; 'PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, A HUSE. S Yes {S S MASS C r �T. Zlpprication for Mi5pogal 6p.5tem icongtruetion Vermi it ` Application for a Permit to Construct(X Repair( )Upgrade( )Abandon( ) ❑Compl a System ❑Indivi4ual Components 'Location Address or Lot No. 40 8 t h a n Lane Owner's Name,Address and Tel.No. William K e r r 'r. Centerville ,Mass. . 02632 32712 Westwood Loop ; Assessor's Map/Pazcel 0 U V 3 Leesburg,F l o r i d a 3 4 7 4,8 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Design,r' Name,Address and Tel.N� 5 0 8—7 75—3 3 3 8J.P.Macomber & Son IKd.! J.P ac ber & Son Inc . Box 66 Centerville,Mass. 02632 Box 664enterville,Mass. 02632 Y Type of Building: Dwelling QLNo.of litarooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type'of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1 Design 355 3x110=330 g gallons per day. Calculated daily flow gallons. " Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1000 + Box Type of S.A.S. Existing pit 6fx12 ' Description of Soil Loamy sand to medium sand . i Nature of Repairs or Alterations(Answer when applicable) a d d i n g t w o 5 0 0 g a 11 o n 1 e a c h i ii g chambers packed in 4 ' of stone with a 3/8" stone cap . — .. _..; Date last inspected: f 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 by thin Bo d of Health. Signed v Date 12/16/`9 9 Application Approved by Date t7— 1 7' Application Disapproved for the following reasons Permit No. — -3 1 Date Issued ea '--------------------------- • i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (t,ertificate of (Compliance 7. THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed 4X)O Repaired( )Upgraded( ) Abandoned( )by J.P.Macomber & Son Inc . at 40 Nathan Lane Centerville,Mass . has been constructed in acc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. 3 dated /t- /7,p r Installer J.P.Macomber & Son Inc. Designer J•P•Macomber & Son Inc. The issuance of this permit shall not,be.construed as a guarantee that the system will function as designed. Date j Inspector �� / /�-- � ------------------ ------ -- No. Fee $ r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mwioonl *raem (EOngt,�uction Permit Permission is herebyranted to Construct X ' Repair .g ( ) p ( )Upgrade( )Abandon( ) System located at 40 Hathan Lane Ceatervilple,Mass. 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-pe t. f� Date: ` ./ Approved by- 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (W=OUT DESIGNED PLANS) I, Joseph P.Macomber J r . , hereby certify that the application for disposal works construction permit signed by me dated 12/16/9 9 concerning the property located at 40 Nathan Lane Centerville ,Mass . meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system ' l � • There is no increase in flow and/or change in useproposed 1 • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation �2-0 +the MAX. High G.W. Adjustment. � � _ ��•�.�_ DIFFERENCE BETWEEN A and B SIGNED : DATE:12/16/99 [Sketch oposed plan of system on back . q:health folder:cent f rI' �' II it 1 Pro ra