HomeMy WebLinkAbout0170 PARK AVENUE - Health 170 Park Avenue
207-143 Centerville
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TOWN OF BARNSTABLE
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VILLAGE C n/1- ASSESSOR'S MAP&PARCEL o2O 7 —l T Y
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IN&TALL- S NAME&PHONE NO. A-1 C0—
SEPTIC TANK CAPACITY -S£ ,4 T C /Al S�EC //�o A o,
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS
OWNER h' G 1'C G A /U
PLC'DATE: 7. 4 - G 6 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 leaching facility) Feet
FURNISHED BY
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SCHULZ LAW OFFICES, LLC
WILLIAM CHARLES PLACE
7 PARKER LOAD
OSTERVILLE, MASSACHUSETTS 02655-2034
TELEPHONE(508)428-0950
FACSIMILE(508)420-1536
ALBERT J. SCHULZ MICHAEL F. SCHULZ
aschulz@schulzlawoffices.com mschulz@schulzlawoffices.com
February 14, 2013
Thomas A. McKean, Director
Town of Barnstable Board of Health
200 Main Street
Hyannis, Massachusetts 02601
Re: 170 Park Avenue, Centerville, Massachusetts 02632
Dear Mr. McKean:
I am writing on behalf of my clients, Justin C. Cronin and Leslie K. Cronin, with respect
to 170 Park Avenue, Centerville, Massachusetts 02632 (the "Property"). As we
discussed on the telephone, the Board of Health records state that the property has a four
(4) bedroom septic. See Exhibit 1. The property is also restricted to four (4) bedrooms
by Section 360 of the Town of Barnstable Code, Protection of Saltwater Estuaries. See
Exhibit 2. Based on the above records and regulations, my clients are aware that the
property is restricted to four (4) bedrooms.
As always, if you have any questions, please do not hesitate to call me.
Very rul Yours,
ha el F. Schulz
cc: Justin and Leslie Cronin
EXHIBIT 1
No��' �.-ll:ir7 d l F�a.�':... Oa...-.._...
THE COMMONWEALTH OF MASSACHUSETTS`
BOARD OF HEALTH
Tor.n Barnstable
...... . O F.......... . ........................
Apli ira#ion for Dhipoo al Wvrko Ton0trurti.an prrniit
APPlication is hereby made for a Permit to Construct or Repair (` an Individual Sewage Disposal
System at
Bacon Dane Centerville., Ma-' 02632 # 89
... ---••------•-----•--•--••-------•••-•----------•------ ----• ................................................-.................................................
Location-Address or Lot No.
Mr. Fr fink Hor a y 89 Bacon Lane Centerville, Ma. 02632
---.._-__..—.-__._...--•--r..._.._ ... ........................... •......_.._-............ ......... .........
•---------
Owner Address
a A & B Canco W..Yarmouth, Mae• 02673 1;350 Main St.) .
i ------
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms...
__.__.......:.:.:....................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___________ No. of persons___________________________ Showers =- Cafeteria
Other fixtures --•----•----•--•-•-•------•-••---•--....• --._....._.. _
WDesign Flow............................................gallons per person per day. Total daily flow___.........................................gallons.
Septic Tank-Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length..................... Total leaching area_______.:____:___:..sq. ft.
3 Seepage Pit No_____ ______________ Diameter________._-_____-__- Depth below inlet..................... Total leaching area..................sq. ft.
Z Other Distribution box ( ). Dosing tank ( )
aPercolation Test Results Performed by........................................................................... Date...................____•----__ _-_.
a. Test Pit No. 1________________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........................
R+ ---•-------•••-------•-••--..•.•------------•-•....................:.................•-•-----------_-... ------•---___-----• ......
-------------------
ODescription of Soil............................................................•--------•--•--•--••---------•---•-------•-----•------------•----•---•-- ----•--- •--•-----•--•-••---•...---
V ....................... -----•-•-•-•--•-•-------•••--•--••-•--•-•---•............................•-._.._..--•---.--•--•--•--------•----------•-•------------•----•-•--
•---•--•--•----•-••---------------------•-•-•----•-•-----•••--•-••----•--•-•--...._.------------------------•--•-----•-••-•-•••---••-------------------•-••-•--•--- •••------•---•---•••-•------
UNature of Repairs or Alterations—Answer when applicable._?_SO.. gallons heavy duty` top septic
t a_nk- and 1000 ciallgn-•s t one.pack_ed leaching Pit. ....................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT11 5 of the State Sanitary 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.
--.—:•y- 1 ....._._.
,� I� f' ----------------------------------
Signed—. Date
APPlication Approved BY :_ t,.W.--�----- ••••.................•-•--- 1 k� /�D Ce
Application Disapproved for the following reasons:___----•-------------•-•-• -------•-----__----------•-•------------•-- ................................
-----•----•---....•-•--•--------------••--•-•-------•---------•-----------------------------•------------•--•----•--•-•-•---•---•••••••----•---- ••-•-•
Date
PermitNo......................................................... Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
................ ................O F...................................._................_..._......................._...
(1-11krtifiratr of fl omptian r
THIS IS TO CERTIFY,That the Individual Sewage Disposal S stem constructed ( ) or Repaired. (X )
by......A & B ta Caco_____________350 Main St. . hr 4. W. Yalemout ".
....... ...... ...........• -- ----.-..._._._..._...---------•--•-------•-•-•-•--•-••••-------•-••--........._
Installer
at.........119 Bacon Lane Centerville Ma. 02632 Frank Horg
•------------
has been installed in accordance with the provisions of TITLE.• 5 of lT,hiel State Sanitary Code as. described in the
application for Disposal Works Construction Permit No_____________---___'.___.__.-____:_._•__ dated ..___._.. _,__�____.__�::�._._..._.....
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. ...... Inspector....................................................................................
Frank Horgan THE COMMONWEALTH OF MASSACHUSETTS
- BOARD OF HEALTH
"P own.........O F._....---Barn s t ab 1�.......f l .....................
No`� ._... p_.._.. FEE....
�►i,��rla���., 'ark,�
Permission is hereby granted......... b_l1!:.......C,..................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No ....._
Street
PPDisposal ' -1►11 1 l�?
as shown on the a lication for Works Construction Permit No Dated_..._______._. __._-__ ................
...............•--..._..--•--•--------...----••----------••--••---------•----•-•--•-•-•-•...---•----•••-
Board of Health
DATE...............}_ i )'• - f
FORM 1255 A. M. SULKIN, INC., BOSTON
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L T ION � � �
S E W A G E PERMIT N0.
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I N S T A LLER'S NAME i ADDRESS
tea"d
A U I L D E R OR OWNER
DATE PERMIT ISSUED
g - IT lc; '
DAT E COMPLIANCE ISSUED
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00o G A P*11' T�
9 N� o's er-e c C N a o ,
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EXHIBIT 2
I Town of Barnstable, MA Page l of 3
Town of Barnstable,MA
Thursday,February 74,2013
Article XV. Protection of Saltwater Estuaries
[Adopted 6-30-2oo8]
§ 3 60-45. Interim regulations.
[Amended 2-10-2009]
A. Purpose.
(1) The findings of a state-wide estuary investigation indicate that a substantial
portion of the Town's saltwater estuaries are in jeopardy from the long-term
buildup of nitrate-nitrogen, primarily from the subsurface discharge of sewage
effluent. These findings have caused the Massachusetts Department of
Environmental Protection to establish total maximum daily loads (TMDL) for
nitrogen for the watershed areas of these estuaries."Watershed"is defined as
the area of land from which water flows downhill into a particular body of water.
In these nitrogen-impaired estuaries the TMDL will require an actual reduction in
the amount of nitrate-nitrogen discharged into these embayments. Since most of
the nitrate-nitrogen in these watersheds is from subsurface discharge of
sewerage effluent into the groundwater that flows to these embayments,and
since it is likely that a plan for corrective action will take years to formulate and
implement,the Board is adopting the following interim regulations to mitigate
the adverse impact to these estuaries from such discharges.The Town has long
recognized the need to protect its water resources and has imposed discharge
limits on subsurface disposal of sewage in other nitrogen-sensitive areas.The
restrictions proposed herein are similar to those imposed by Town ordinance
and/or Board of Health regulation in other nitrogen sensitive areas in the Town.
These regulations are temporary and will be in effect only until the Town adopts
and implements a Comprehensive Plan to address the nitrogen reduction
required in these estuary systems by the proposed TMDL.
(2) To date,final reports have been produced for Popponesset Bay,Three Bays and
the Centerville River watersheds.All three of these estuary systems will require a
reduction in total nitrogen discharge in order to meet the state-mandated TMDL.
Further reports are expected on Lewis Bay and Barnstable Harbor.
B. Restrictions. No permit for the construction of an individual sewage disposal system
on any building lot shall be granted within the watersheds for the estuaries that have
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Town of Barnstable, MA Page 2 of 3
been identified as requiring a reduction in the current TMDL of nitrate-nitrogen as
identified by the map entitled"Massachusetts Estuary Project,Zones of Contribution
to Saltwater Estuaries,Town of Barnstable, March 10, 20o8,"unless the following
standards are met:
(1) The maximum allowable discharge of sanitary sewage, based on the sewage
design flow criteria listed in 310 CMR 15.203,Title 5,of the State Environmental
Code, shall not exceed 440 gallons per 40,000 square feet of lot area,with the
following exceptions:
(a) For approved building lots on which no building currently exists and that are
less than 30,000 square feet in area,the maximum allowable sewage
discharge shall be 330 gallons.
(b) For parcels with existing buildings,the maximum allowable flow shall be either
440 gallons per 40,000 square feet,except as described in Subsection 1130)
(a) above or whatever is currently permitted,whichever is greater.
(2) Nothing in this regulation shall prohibit the approval by the Board of Health of
any application involving the maintenance, repair or alteration of an existing
individual sewage disposal system, provided that said application does not involve
an increase in design flow as defined by existing Board of Health regulations.
Where an increase in design flow is involved,the applicant must demonstrate
compliance with this regulation.
C.Variances. A variance from this regulation may be granted by the Board of Health only
if the applicant can demonstrate that:
(i) Connection to Town sewer is not available;and
(2) That enforcement thereof would do manifest injustice;and
(3) The alternative proposal will provide the same degree of environmental
protection as a design in full conformance with this regulation.This standard
shall be met by a site/septic design which results in equilibrium concentrations of
nitrate/nitrogen at the down-gradient property line not exceeding five ppm,
utilizing the Cape Cod Commission formulas found in its Technical Bulletin 91-
ooi (final). In undertaking this calculation,the applicant may utilize off-site lands
located elsewhere in the Estuaries Contribution Area as defined by the map
entitled "Massachusetts Estuary Project,Zones of Contribution to Saltwater
Estuaries,Town of Barnstable, March 10, 2008,"provided that:
(a) The existing nitrogen loading for the off-site property is included in the
calculations;and
(b) A deed restriction limiting the off-site property to the current nitrogen
loading as stated in the calculations and running to the Barnstable Board of
Health or other entity suitable to that Board is recorded at the Barnstable
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i
Town of Barnstable, MA Page 3 of 3
Registry of Deeds in the titles to both the subject property and the off-site
property.The restriction shall be in a form suitable to the Barnstable Town
Attorney. Proof of recording shall be provided to the Board of Health,the
Town Assessing Department and the Town Building Department prior to the
issuance of a DWIP for the subject property.
D. Craigville Beach District implementing regulation. Notwithstanding anything to the
contrary contained in Subsections A through C above,this interim regulation shall
apply to all properties within the Craigville Beach Zoning District as a Craigville Beach
District implementing regulation unless and until a property is connected by a
building sewer to the public sewer system. In all other respects,the provisions of
Subsections A through C above shall apply to all properties within the Craigville
Beach District. [Adopted 1-19-2011 by Ord. No. ii-oi of the Barnstable County
Assembly of Delegates pursuant to Ch.716 of the Acts of 1989 (Cape Cod
Commission Act)]
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y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010,
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: A. General Information
When filling outiL
.forms on the .� 1
computer,use 1. Inspector: rTF
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
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 mainte nce of on site
sewage disposal systems. I am a DEP approved system ins In ( n 15.340 of
Title 5 (310 CMR 15.000).The system:
D
® Passes ❑ Conditionally Pass AUG P50�1
❑ Needs Further Evaluation by the Local Approving Auth rity /I / y _
By
8/25/2010
Inspector's Signatu 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.
�j
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage 6isposal System-Page 1 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
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:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N FIND (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 FIND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
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 Y2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
•r:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
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.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2008:213,000
g ( y g (gp ))' 2009:230,000
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 8/25/2010
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 Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every 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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
7'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
6,
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: 1500 gallon
Sludge depth:
4"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every 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
28"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
7"
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.):
r •
Tank needs to be pumped.Pump tank every two years.lnlet and outlet tees are in place.No evidence
of Ieakage.Tank appears structurally sound. Y
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Park Ave.
M
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
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 ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every 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 No
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 is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
.1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.No signs of hydraulic failure.Water level was 16" below invert at time of inspection.Stain
line observed 12" below invert.
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
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 21'
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:
As-Built.
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
170 Park Ave.
Property Address
William Price
Owner Owner's Name
information is required for Centerville Ma. 02632 8/25/2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any way.
A. General Information �y
1. Property Information: MAP 207— PARC 143
170 PARK AVENUE — CENTERVILLE, MA 02632 3 go?
Property Address
HORGAN, FRANK
Owner's Name
170 PARK AVENUE
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
SEPTEMBER 1, 2006
Date
2. Inspector:
JAMES D. SEARS
Name of Inspector
A & B CANCO
Company Name
350 MAIN STREET
Company Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
508-775-2800
Telephone 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:
RPasses ❑ Conditionally Passes ® Fails
eds Further Evaluation by the Local Approving Authority
ector'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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
i t
COMMONWEALTH OF MASSACHUSETTS
G
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. Certification (cont.)
170 PARK AVENUE
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
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:
B) System Conditionally Passes: N/A
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
ND Explain:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
i
COMMONWEALTH OF MASSACHUSETTS
Title 5 Official Inspection Fora
9 C
Not for Voluntary Assessments
See Subsurface Sewage Disposal System Form
B. Certification (cont.)
170 PARK AVENUE
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
B) System Conditionally Passes (cont.): N/A
® 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
obstruction is removed
distribution box is leveled or replaced
ND Explain:
® 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
obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health: N/A
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
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
f
Y
i
COMMONWEALTH OF MASSACHUSETTS
Title 5 Official Inspection Form
q C
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
170 PARK AVENUE
Owner's Address
CENTERVILLE MA 02673
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
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 that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3.Other:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
COMMONWEALTH OF MASSACHUSETTS
w Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
170 PARK AVENUE
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
D) System Failure Criteria Applicable to All Systems: N/A
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 pit is less than 6" below invert or available volume is less than
'/z 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 surface water elevation.
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary
to a surface water supply.
® N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
® N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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.]
YES No
QT . The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd.
Yes No
® 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
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: N/A
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
s�. Subsurface Sewage Disposal System Form
C. Checklist
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
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?
® 0 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, including 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)].
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
COMMONWEALTH OF MASSACHUSETTS
w u Title 5 Official Inspection Form
a
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
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
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection is required] ® Yes ® No
Laundry system inspected? ® Yes ® No
Seasonal use? ® Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ® Yes ® No
Last date of occupancy:
Commercial/Industrial Flow Conditions: N/A
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:
Last date of occupancy/use:
Date
Other(describe):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
General Information
Pumping Records:
Source of Information: N/A
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)
Tight tank. Attach a copy of the DEP approval.
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site? ® Yes ® No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
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COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Fora
e� Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
Building Sewer(locate on site plan):
Depth below grade: 5
feet
Material of construction:
® cast iron [3 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: 6
feet
Material of construction:
0 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: 1500-GAL PRE CAST
Sludge depth: 26"
Distance from top of sludge to bottom of outlet tee or baffle 4"
Scum Thickness 4"
Distance from top of scum to top of outlet tee or baffle 8"
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? TAPE,PROB&SLUDGE JUDGE.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
COMMONWEALTH OF MASSACHUSETTS
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Not for Voluntary Assessments
p^ V0V
Subsurface.Sewage Disposal System Form
D. System Information (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
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 AT WORKING LEVEL WITH STEEL COVER AT GRADE-OUTLET TEE.
NO SIGN OF OVER LOADING OR LEAKAGE.
Grease Trap (locate on site plan): N/A
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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): N/A
Depth below grade:
Material of construction:
® concrete ® metal ® fiberglass ® polyethylene ❑ other(explain)
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page I I of 16
COMMONWEALTH OF MASSACHUSETTS
m Title 5 Official Inspection Form
R � e
Not for Voluntary Assessments
41 y0y
Subsurface Sewage Disposal System Form
D. System Information (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
Tight or Holding Tank (cont.) N/A
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 a copy of current pumping contract(required). Is copy attached? ® Yes 1:1 No
Distribution Box(if present must be opened) (locate on site plan):,(
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-BOX IS 7' BELOW GRADE, USED CAMERA TO INSPECT BOX, LOOKS CLEAN
& SOLID. NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
Pump Chamber(locate on site plan):
Pumps in working order: Yes ® No,
Alarms in working order: Yes ® No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
COMMONWEALTH OF MASSACHUSETTS
Title 5 Official Inspection Form
n
Not for Voluntary Assessments
V v
Subsurface Sewage Disposal System Form
D. System Information (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
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:
LEACHING NOT LOCATED AS OVER & BELOW GRADE.
LEVEL IN TANK AND D-BOX SHOW NO SIGNS OF OVER LOADING.
Type:
0 leaching pits number: 1
leaching chambers number:
Elleaching 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.):
LEACHING IS ONE (1) 1000-GALLON PRE CAST PIT.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
COMMONWEALTH OF MASSACHUSETTS
A Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A
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, damp soil, condition of vegetation,
etc.):
Privy (locate on site plan): N/A
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
r
COMMONWEALTH OF MASSACHUSETTS
a v Title 5 Official Inspection Form
c
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
Sketch of Sewage Disposal System: Provide a sketch 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.
�] 3
O
ule Otticia!Insr, cct n:::,rm:SWISUrl We Sep.age�:r;hr•,a1 j,qp;;t;
COMMONWEALTH OF MASSACHUSETTS
ro Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
170 PARK AVENUE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
HORGAN, FRANK
Owner's Name
SEPTEMBER 1, 2006
Date of inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to NO ground water: 18'
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:
AREA HIGH — NO SIGN OF GROUND WATER.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
AUG. 16. 2005 (VIED) 08:i 3 CENTER•/ILLE FIRE 5087902385 PACE-2
Make appllc*Q m!to.fodrai•:'Fje':tMpa atilt.
Fire Dppartettent retains original appUcatlon and IiSW64 duplicate as permit.
L'd GEafL w&
. APPLICATION and PERFAIT Feo:;��,®
for:storms tank reMoval end transportation to reproved tank disposal yard in awordance with the provisions
Of M,t L. (Chapter 148, SWUM 38A,627 CM R 9.00,application is hereby made by:
Tal*Owner flame(pfea�w pr9rlt)I KAv k �. . Now
Y Frank.Corp. Environmental Services
70o. iradiWduW
Address 6 55 Tarklin Hill Rd., New Bedford, MA 02745
Address �T
6Wuft're(if aplilft for p®rr*) S igmtUre(if applying For permit)
Mar - ®IFCI 0"fied CQ LSP Ai Other
Terik Qp0diy(gQ0M) SCC �
Sabstmnco Lx*storod
Tank lit ansione(diait►Ater x
f�krrt 4rattis194roing waste �, ,Cc , !" Sttafe.fJo.fi Ll
IHazaardws wote titewem E.P.A.#
Appw#)d Uw*apoaW yw(f C�ram- CR -fw*yard# L
Type of lied fpe �- _Taelc yard adds +_Tt La T a 4.�.c ➢ „�
City or Town ZQ
Date of Issue w _, ,Date of eupin tlon .r-
Dig sdo approval nurr►ber. pfg Safe Tel Frm Taf.Number•soo-822-4644
Signature/We of(Moor grortting permit ,tee �,,,�, i-AP
Alter rerr ioval(s)amW Fwm FP-2.0M signed by L4c W Rm DopL t®UST Reguielory CcOmolance Unil,000 Aeiatwrton place,
Room 1310.DoGton,MA021M1$i@-
FP•262(revised&06)
J
L T10N SEW
A 6 E PERMIT NO.
V r
E
INSTA LLER'S NAME A ADDR-ESS
e UILDER OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIA.NCE ISSUED
-l� a
P000
1 �Pt
t
lSoo mQ C'N 2-0 ) Gam@
1 oao
.p i
� l CAT10 SEWAGE PERMIT NO.
I N S T A LLER'S NAME 16 ADDRESS
A . Ps , ,=
d U 1 L D E R OR OWNER r
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
A 1
AA
bo °0 C lSo�k o
J'Ooo
I S o o m Q C N ao j CLU
000 p tt
1
No��..::�'�r7� J Fzes.��500..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
00 ...............Town................OF......Barnstable..
r Appliratiun for Disposal 10orkfi Tuntrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
Bacon Lane Centerville, Ma. 02632 # 89
.........._........................... ------ --------•-••.......----------•-••-•-•-•.....-•-----•-•-•........._.._..............
Location-Address or Lot No.
Mr. Frank Horoan 89 Bacon Lane Centerville, Ma. 02632
......................- ----• •-••----..... . ..........••-------•-------•--•-•---••---•-•.....••-•••---•------•-----------•...............•
Owner Address
a A & B Canco W. Yarmouth. Ma. 02673 �350 Main St.)
-•---..... --------•--
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........--------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures ......................................................
Design Flow............................................gallons per person per day. Total daily flow.___.._..................._.,----- -_-----gallons.
W. ,..
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~" Percolation Test Results Performed b ............................. ... Date........................................
Test Pit No. l..............:.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........................
a •-••--•--••---------•••--•-•----•---••••--•-•••-....••-••--•••-----•-•-------•-----------•---•...............................................................
ODescription of Soil........................................................................................................................................................................
W -••-••••--••---------•••-•-•-------------•-•--•--••---•----••-•••-•••••••••--•-•••••-••---•------••---•-••-••••-••-•••---•-•••-•-----•••-----•-•••••-•••••-•.....--•----•---......................----•-
U Nature of Repairs or Alterations—Answer when applicable_1SPP..callons heavy duty toy septic
ank...and_.A000..ga1lon... tone...packed._le.achi.ng..pil.............................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System,in accordance with
the provisions of TITA U 5 of the State Sanitary 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. I
Signed--- mac. -------- .........
Date
Application Approved By........ ��:� -------------•-•----••-•------......................._ ..........
Date
Application Disapproved for the following reasons:----------•----•-----•------•--•--------------------------•------..............................................
....................•----•---•-----•-•---•------.....----._....------------------------......--------•----•-------------••--•••••---••-•----••-•--••••••-•-•------•---•••-•-•-•---••---..............•--
Date
Permit No......................................................... Issued._.....--.....:
Date
Noo —1 t`-T.f. FRs$15.00..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....Town................OF.....Barnstable
.................................................
Appliration for Mipogal Works Tonstr trtion "perm#
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
Bacon Lane Centerville, Ma. 02632 # 89
....:..........._...........................---...-----.....-•----------------................... ---....---••-•--......--------•---•••....._.....--•--••--•----•---.............................._.
Location-Address r Lot No.
Mr. Frank Horgan 89 Bacon Lane denterville, Ma. 02632
•--•---•----------. - ... -------------------•-------..._...---_.... ......................................................... .......----......------..._
Owner Add s
a A & B Canco W. Yarmouth, Ma. 073 (350 Main St.)
................
- -- -------------•--.....--•:--•--......-•-------•--...------•---•-
Installer --
� Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.......Y.................................Expansion Attic ( ) Garb, Grinder ( )
WOther—Type of Building ............................ No. of persons............................ Showers.,( ,) — Cafeteria ( )
dOther fixtures .....-----•----•---------•----------------------------.-------------------•---•---•------------...-- =
W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length.............•.. Width................ Diameter................ Depth................
x. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1'4 Percolation Test Results Performed bY.......................................................................... Date........................................
.4
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(sI Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -------•-•---•---------•••----•--•-•----------••.........--••-•......---•-•-••-•-•-••-•-------------..........................................
•-----------
---
0 Description of Soil.........................................................•..............................................................................................................
U •-•-----•--•-----•................•------•--•••.......-•••••••--------•-•..........-•------•--•-••---•-••••••-•--••----......_...----------•••--•---•-•.....-•-----•.._..•------------•----......_......
W
--------------------------------------------------------------------------------------------------------------------------------------••------------•-----------------------------------.........
V Nature of Repairs or Alterations—Answer when applicable gallons heavy duty top septic
p - --- --- - u ------ s --- •-.-...._.
tank and 1000..9allon_.stone- packed leaching pit•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary 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. ,�^
- .11A g.'
Application Approved By.................. .........�... `.'�
Date
Application Disapproved for the following reasons-------------------------•............------------------------....---------------•---•-•••-•-••----•-•-•----•---
•--•-•....................••••••-•••-----...........•••--••.....•--•----•-----••••-----•--••---------•-•-•--------.............--•-----•---•••-------••-•--•----••------•-••••••---•----•••-----...-•---
Date
PermitNo.....................••..............................._ Issued_......................................................
-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
..........................;...............OF.....................................................................................
Trrfifiratr of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X )
A & B Canco 350 Main Si. W. Yarmouth, ....
by.-------••-•..........••--•--•••---•--..........•---•-•----•--•..................•••-••---••-•-• ------•----•--------.-•--
89 BaconInstaller
at------
..... .....
has been installAd in accordance with the provisions of TITLE aof T e State Sanitary Code a described in the
application for Disposal Works Construction Permit No.._._.�..:`"'__.t�1..._... dated......_..!�_J_P_14`".�'
. ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
2
G�
DATE....................... ,.--�......:.��..f..��7.-=--==--=�==:..---. Inspector....................................................................................
Frank Horgan THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town..........OF.........Barnstable
II ................................ ...5.00..............
No.... . . FEE.... �t
...... ...... ....
Dispas ork.5 Tondrurtion lirrutit
Permission is hereby granted. ------.�--..?1�1�on -......
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo.......... ' .c ._ ....-- r: .... .--•---•--------------------•-••------...---------------------------------•-•-•----...................--•-
Street )
as shown on the application for Disposal Works Construction Permit NFo.... s ��!_ �_ Dated-------------�-_t.t� ..............
........-•-•••-•-•-----••--••---•-•-•------•-----•-•--••--•-••...
1. I Board of Health
DATE " ---•-•-•...............•--.-----
FORM 1255 A. M. SULKIN, INC., BOSTON
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