HomeMy WebLinkAbout0089 PINEY POINT DRIVE - Health 89 PINEY POINT DR.
CENTERVILLE
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UPC 12534
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r Message Page 1 of 1
Flynn, Judith
To: Health
Subject: RE: 89 Piney Point Drive,Centerville
Mr. Jack...
Your question about 89 Piney Point....The system is adiquit(for 3 bedrooms )
Your second question...Is the basement bedroom legal?....you will have to talk to the Building Department
- 508 862 4031
r
Hope this helps...
-----Original Message-----
From: McKean, Thomas On Behalf Of Health
Sent: Monday, September 26, 2011 1:49 PM
To: Flynn, Judith
Subject: FW: 89 Piney Point Drive,Centerville
-----Original Message-----
From: Jerry Jack [mailto:jjack@todayrealestate.com]
Sent: Monday, September 26,.2011 12:15 PM
To: Health
Subject: 89 Piney Point Drive,Centerville
The assessors office shows subject property as a two(2)
bedroom dwelling .However, MLS shows it as a three(3)
bedroom dwelling, with 2 bedrooms located on main floor
and another in the basement.
Please clarify if current septic system is adequate for j
3 bedrooms and if 3rd bedroom is legal.
Thank you,
Jerry Jack
..........................................................................................................................................................................................
Jerry Jack
..� Today REAL ESTATE
487 Station Avenue
South Yarmouth, MA 02664
Local Phone: (508) 568-8161
Toll Free: 800-966-0369
€www.todayrealestate.com
B _f A.L Click here for my vCard
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TEXT "Ta ►' aa 'TO! 777
T(0 't6Lt' ,':LL'r"L LIST 1P1GS ,FOR: SALE CON CAPE C.01D
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9/26/2011
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
h
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
information is y
required for Centerville MA 02632 May 13, 2011
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 out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Darren M. Meyer
cursor-do not Name of Inspector
use the return
key. n/a
Company Name
PO Box 981
Company Address
East Sandwich MA 02537
City/Town State Zip Code
781-424-6748 S13920
Telephone Number License Number
B. Certification
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 ❑ FailsLl
-
`�J :a
Needs Further Evaluation by the Local Approving Authority a ";
Inspector's Signature Date
The system inspector shall subm 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.
r
t5ins•09108 e 5
Ti
it I Offlclal Inspection Farm:Subsurface Sew 1 Disposal System•Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
a
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
information is required for Centerville MA 02632 May 13, 2011
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure c6terla not evaluated are
indicated below.
Comments:
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):
t5lns•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
Information Is Centerville MA 02632 May 13, 2011
required for _ Y
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines In accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108 Title 5Offcial Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
m
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
information is required for Centerville MA 02632 May 13, 2011
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cunt.)
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
❑ N 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
information is required for Centervilley
MA 02632 May 13 2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS;cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well,
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd,
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area —IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15,304. The system owner should contact the appropriate
regional office of the Department.
t5ins-09I08 Itle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
Information is Y
required for Centerville MA 02632 May 13, 2011
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): 350
l5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
ti
I
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
y
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
information is Centerville MA 02632 May 13 2011
required for Y
every page. Clty/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): 2009: 68 gpd
Detail 2010: 42 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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 6 Official Inspection Form:Subsurface sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°P 89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
Information Is Centerville MA 02632 May 13, 2011
required for Y
every page. City(rown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
u d Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
information Is Centerville MA 02632 May 13, 2011
required for Y every page. Cit frown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System installed 2001, system is 10 years old.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
12"
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
No signs of leakage.
Septic Tank(locate on site plan):
Depth below grade: J 12 inches
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: typical 1,500G tank
Sludge depth: 3 inches
• tNns•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address `—
Bornstein
Owner Owner's Name
Information is Centerville MA 02632 May 13 2011
required for Y
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 31 inches
Scum thickness 0 inches
Distance from top of scum to top of outlet tee or baffle 0 inches
Distance from bottom of scum to bottom of outlet tee or baffle 0 inches
How were dimensions determined? tapes and rods
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level equal to outlet pipe, structural integrity is sound, no sign of leakage, no sign of hydraulic
failure, PVC tees with baffle is in place.
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
t51ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 10 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Piney Point Drive
Property Address -
Bornstein
Owner Owner's Name
Information is y
required for Centerville MA 02632 May 13 2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Officiai Inspection Form;Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
u w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
Information is Centerville MA 02632 May 13, 2011
required for Y
every page. Cityfrown 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 n/a
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.):
D63- D-box is 48" below grade, no riser in place, box is level, no sign of solids carry-over, no sign of
leakage, no sign of hydraulic failure or overflow.
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:
t5lns-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
9Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,- -VW 89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
Information is Centerville MA 02632 May 13, 2011
required for Y
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ 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.):
2 - 50OG Leaching Chambers w/4ft stone between, 3 ft stone on sides, and 2 ft stone on ends.
chambers 36" below grade w/ 1 riser to 12" below grade. Vegetation normal, soils normal, Chambers
are dryer
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
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�r 89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
information is Centerville MA 02632 May 13, 2011
required for Y
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 T1tle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
e
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
Information Is Centerville MA 02632 May 13, 2011
required for Y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A
9
3
A� 25 b-
t
A- 2 11
A - 3 . vqi �_3 ; 31
A - 3o g _c,
t5ins•09/08 Title 5 Off cial Inspection Form;Subsurface sewage Disposal System•Page 15 of 17
s
Commonwealth of Massachusetts
Title 5 official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ye 89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
information
formation Is Centerville
squired for MA 02632 May 13, 2011
every page. Cityfrown 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: 141"
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: 10/22/2001
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:
Bottom of system approx 5.5 ft. below grade, based on elevations listed on design plans w/
groundwater greater than 12 feet below grade, system is not within adjusted groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Mrs•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
u W Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Bornstein
Owner Owner's Name
Information is Centerville
required for MA 02632 May 13, 2011
every page. Cityrrown 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
Wins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17
_ _ pl
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 89 Piney Point Drive 4"���'1
Property Address
Dorothy Bernstien � DO-1
Owner Owner's Name
information is required for Centerville MA 02632 03/25/08
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.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Michael Kellett
cursor-do not Name of Inspector
use the return
key. Aardvark Environmental Inspections
Company Name
VQ P.O. Box 896
Company Address
East Dennis MA 02641
City/Town State Zip Code
508-385-7608 S13742
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. Thg inspection
was performed based on my training and experience in the proper function and maintenanceof on'-site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 45.340!bf
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Faa
❑ Needs Further Evaluation by the Local Approving Authority
n
4_
I i v"�✓' 03/25/08
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the Inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
*"**This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
<L Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is Centerville MA 02632 03/25/08
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
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:
13) 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.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
x
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:
❑ 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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
fail•08/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is Centerville MA 02632 03/25/08
required for
State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ 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:
❑ 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
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.
fail•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is Centerville MA 02632 03/25/08
required for State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (coat.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
El ® 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
fail•08106
c Ct)mmonwealth of Massachusetts
w Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
owner Owner's Name
information is required for Centerville MA 02632 03/25/08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
❑ E 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.
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�M 5 89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is Centerville MA 02632 03/25/08
required for
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)]
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
fail•08106
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is Centerville MA 02632 03/25/08
required for State Zip Code Date of Inspection
every page. City/Town
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 �
1
Number of current residents:
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 M No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Current
Last date of occupancy: Date
Commercial/Industrial Flown 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:
Last date of occupancy/use: Date
Other(describe):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
fail•08106
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a' 89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is required for Centerville MA 02632 03/25/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
11/14/01 per BOH
Were sewage odors detected when arriving,at the site? ❑ Yes ® No
fail-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is required for Centerville MA 02632 03/25/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2:5feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.8feet
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 gal
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
Z"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 16
How were dimensions determined? measured
fail•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Cbmmonwealth of Massachusetts
W Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is required for Centerville MA 02632 03/25/08
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.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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):
fail•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
i
Commonwealth of Massachusetts
N v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is required for Centerville MA 02632 03/25/08
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert even
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.):
The box was level and tight with no sign of carryover
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
fail-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is Centerville MA 02632 03/25/08
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
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:
Type:
❑ leaching pits number:
2
® 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.):
This system has two five hundred gallon dryweels surrounded by three feet of stone. There was no
sign of ponding or failure.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
fail•08/06
Commonwealth of Massachusetts
W Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owners Name
information is
required for Centerville MA 02632 03/25/08
every page. City/Town State Zip Code
Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is required for Centerville MA 02632 03/25/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
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.
)v
fail•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 89 Piney Point Drive
Property Address
Dorothy Bernstien
Owner Owner's Name
information is required for Centerville MA 02632 03/25/08
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show anelevation of over twenty feet.
fail-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
oF r
Town of Barnstable
t�
Regulatory Services
BARNSTABM ; Thomas F. Geiler,Director
KAM
9�plf16.39. Public Health Division
Thomas McKean,Director .
200 Main Street, Hyannis, MA 02601
Office: 508-8624644 Fax: 508-790-6304
This sep
tic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although-the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
not does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
TOWN OF BARNSTABLE L
LOCATION X ? -Z,&e,X eQ lAl f 9,0o SEWAGE #I O®t._ 7 0 9
VILLAGE Ce V 'eA V ASSESSOR'S MAP & LOT z$"0u
INSTALLER'S NAME& PHONE NO. �,L /�I Q✓�/�e l�
SEPTIC TANK CAPACITY 1,,f 0
LEACHING FACILITY: (type);k— AQ P (size) /020"•— 29
NO. OF BEDROOMS 3
BUILDER OR OWNER (VWPr.S 60t, 11,
PERMIT DATE: I I ��U f COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) t Feet
Furnished by
�. t:p �
d� o'c
v,J
I�
4
No. Fee$ 5 0.0 0
�, /
�. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -^7//
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for Migogal Opotem (Construction Permit
Application for a Permit to Construct( )Rep ' Upgrade-a)Abandon( )XkkComplete System El Individual Components
Location Address or Lot No. 89 Piney Point Drive owner's Name,Address and Tel.No.Morris Bornstein
Centerville,MAss.02632 89 Piney Point Drive
Assessor'sMap/Parcel A 9 7 Centerville,Mass.02632
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 IH6.. Ronald J. Cadillac
Box 66 Centerville,Mass.02632 1P.O.Box 258 West Yarmouth,Mass.0267
Type of Building:
Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder WQ
Other Type of Building T a S. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 350 gallons per day. Calculated daily floc 1 4. 1 S F=1 5 9.3 S F gallons.
Plan Date 10122101 Number of sheets ReAionbh ePd/SF
Title
Size of Septic Tank 1 S(Lp bnx Type of S.A.S. 2-5 n n fa 1 1 on chambers
Description of Soil: Sandy loam to coarse sand- Iry -I, on £rzS
re of Repairs or Alterations(Answer when applicable) Omitting c e s s op n 1 R Installing
M500 gallon septic tank, 1 -Distribution box and two 500 gallon leachin
chambers ers pacReci in s one.Per plan.
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 iss d by this PAar f H .
Signed Date 1 1 /2/01
Application Approved by Date 1�
Application Disapproved for the following reasons
Permit No. C1 Date Issued I
pp �
z -
r�-�� / � „' « .� Fee 50.00
0.
< THE COMMONWEALTH OF ASSACHUSETTS Entered ti omputer:
'' Yes
PUBLIC HEALTH DIVISION z TOWN OF BARNSTABLES MASSACHUSETTS
Zipplication for llhgozar Op$tem Conmruction Permit
Application for a Permit to Construct( . )Rep aiY'( Upgrade(�)Abandon( )}{ Complete System El Individual Components
Location Addressor Lot No. 89 Piney Point Drive Owner's Name,Address and Tel.No.Morris Bornstein
Haehpee�fil&sV 828402632 89 Piney Point Drive
Assessor'sMap/Parcel g r s I? Centerville,Mass.02632
Installer's Name,Address,and Tel.No.5 008—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(.Macomber & Son nc. Ronald J. Cadillac
Box 66 Centerville, ass1:02632 1P.O.Box 258 West Yarmouth,Mass.0267
Type of Building:
Dwelling XX No.of Bedrooms_-._.3._ ----- Lot Size sq.ft. Garbage Grinder WQ
Other Type of Building Lb S. No.of Persons Showers( ) Cafeteria( )
Other Fixtures '
Design Flow 350 gallons per day. Calculated daily floc 14 1 S F=1 5 9.3 SF gallons.
Plan Date 1 0/2 2/01 Number of sheets Re-&bn MgPd SF
Title '
Size of Septic Tank 1 500 + hr)w Type of S.A.S. 2-5130 ola 1 1 on chambers
Description of Soil:Sandy,,,loam to coarse sand. '�/ ` Skor, , On f��5
Na ogR,e or Alterations(Answer when applicable) Omitting cesspools. Instal l f n
I 00 gpa�lon septic tank, 1-Distribution box and two 500 gallon leachi,n
Chambeis packedin s one. er p an.
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'iss d by this Boar f Hea •h.
Signed
` a r Date 1 1 /2/01
Application Approved by n /� .� r Date 1/ 3/c
Application Disapproved lor the following reasons
Permit No. Date Issued 1
---------=------------—----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )UpgradedK(XXy
Abandoned( )by J.P.Macomber & Son Inc, 11 '
at 89 Piney Point Road Centerville,Mass. has been constructed i accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. %UJ�-� &dated 16
Installer J•P.Macomber & Son Inc. Designer Ronald J. Cadilac
The issuance of t 's permit shall not be construed as a guarantee that the system will function as.designed.
D ��ate� 2no 1 Inspector A&4 M1 21ta1A
----------------------------------- ----
No. )C�f �"ll�� Fee 50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
niopozal 6potem (Construction permit
Permission is hereby ranted to Construct( )Repair( )Upgrade(XX)Abandon( )
r System located ate 18j,. Piney Point Road Centerville,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:Construc ion must be completed within three years of the date of-this permit.
Date: 'Approved by
�g
g
-Z
OEM-
ZCA7n,C iie
A, M
rP-
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MILLAd
NAME&P HO NO.,11,10_
A4 A coAg 13 e ifr .5,C,,41
SESEPTICTAN
K:'C�
LEACHING TACIL
(size) 0,/
(type)
NO. OF BEDROOMS BUILDER OR OWNER (Vlopr
I COMPLIANCE-DAT PERMIirDAi�:.
V
paration Distance 8'e'tw e'en thi:
�MaAyffim Adjusted Groundwater
Table to the Bottom-
of Leac
hind fadi y
Pn�' teWAter SdpoI�Wqlland.U'a ingFad tyIf any iwells!exist
"
ion site or wi"h-20Tfept of I '' ng'faci ty),;.,,�,,eac hi'
Edgeiofyv aland'in d-Leaching Facfiiy.:
(Ifahy wetlands exi
st
facility)
Cb -,,eazmng-�difi 3W,
Fqrr
7
�K_J
'T
'R
'4 4 -�A
70a A 7
..........
Town of . 'bA-r" 10 Le - Date
Date Scheduled 141 O 1 ' Time D`v A-yv J
Soil Suitability Assessment for Sewage Disposal
Performed By: ft. . J, CA��( Il�Q� Witnessed By:_ LG
CATI(DN& GENERA L INFORMATION'
Location Address Q/] �N �Q/�r D7 Owner's Name , t,�,,
C/J`�l r ' F l ID�r,►''t�S B®rAJS &
LG JTFQVI L.L r Y (?A Address q'I tN
_ sy Pn,:�7 p
Assessor's Map/Parcel: Z,8 /�0-7 Engineer's Name ('EN77-!2v1Ie_C6-
>2 .J CA61,�►i
NEW CONSTRUCTION REPAIR _�)4 Telephone N —7 _'71
Land Use 1/Wt=.I Slopes(%)_ �1_ Surface Stones` �1 0
Distances from: Open Water Body -Il Possible Wet Arca_-PI Pr It Drinking Water Well R
Drainage Way R Property Line 1, -> n -Other (t
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
(oor
ofi�°b
H 0.
� I �
1 ®D
j-� Parent material(geologic) Depth to Bedrock
�—�- Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
riE TEM.
...............
................
........
NATION Ffl►R SEASONAL HIGH'WATE�i TABLE
Method Used:
Depth Observed standing in obs.hole: 7l/ in. Depth to sod mottles in.
Depth to weeping from side of obs.hole: A11A in. Groundwater Adjustment —ft.
Index Well N,rZ�.Reading Date:,.wNrr Index Well lave . _ Adi.factor C 7_ Adj.Groundwater Level_ Z 6
P:ERCCLATION TEST Date': T�rne :
Observation
Hole N Time at 9"
Depth of Pert; io Q Time at 6"
Start Pre-soak Time @ Time(9%6")
End Pre-soak �Q / iie�— g `///4Q
Rate Min./Inch2 „�;
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division ' Observation Hole Data To Be Completed on Back—�
Copy: Applicant
Poo
bEEk bBSERVATIO.N I1 :u LOG ;)Mole;#; .
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency, Gravel)
a/3 ' A iVD
iv o
DEEP IBSERVATION H!DLE L+OG Hole#
..
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
0
2 Gravel)
bEEI'0 SERV;ATION HUI.E LO;G Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistencv,%Gravel)
0
DEE OBSERVATION H POLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,°o rave
r:
r
.Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No— Yes
—" —Within 100 year flood boundaq`No'- --Ycn
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification �y Z
I certify that on VOL) • ��7/ (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the require expertise and a fence described in 310 CMR 15.017.
Signature Date �O ��
T �®
JOB NO. BC='1-1G
1, LOCUS IS A.M. 228, PARCEL 7.
2. ELEVATIONS SHOWN ARE TOWN G I S ±101.5'
3. L! ; l,;r; IS IN FLOOD ZONE C ON FIRM DATED AUIG!.!`;T 19,
4. ALL PIPES TO BE 4' CH 4:,,, ANC? PITCHED AT 1/4" FIEF, FOOT. %.,NLU,<, NOTED",
rj
5. MUNICIPAL WATER IS AVAILABLE. LOT`:; WITHIN 1--` ARE ON TOWN WATER.
G . 6. COMPONENTS TO BE AASHTC H-1 ?, !)NLE >S NOTE[.
�t 7. INLET TEE TO PROJECT [)OWN 13", OIJTLET TEE [TOWN 14". M�1/
8. IF TWO OR MORE LINES, WATER TEST G-BOX FOR EC:%l..IAL FLOW r:1REET
D-BOX EXIT PIPE.`: TO BE LEVEL FOR FIRST TWO FEET. NOT TO
C. [DEPTH OF C:'� MPONENTS NOT TO EXCEED 3', OR VENTING MUST BE PROVIDED. `;SALE
BUILD, I,1F' COVERS TO WITHIN 1' OF GRADE, MORTAR CHIMNEYS IN PLACE.
ONE :'!OVER OF TANK TO BE WITHIN ('5" OF GRADE. TI�a AP
.10, STONE TO BE DOUBLE WASHED 3/4 TO '1 1/2" WITH 2" MIN. 1/8 TO '112" PEA STONE ON TOF'.
11. IF UN,"UITABLE SOILS, OR SOIL`:` [DIFFERING FROM THE SOIL LOG ARE FOUND,
CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC.
12. IF AN OVER[DIG IS C;ALLEP FOR BELOW, FILL MATERIAL FOR `" AROIJNC' AN[D l..!NC'ER LEACHING TEST HOLE 1
IS TO BE CLEAN GRANI..JLAR SAND MEETING SPECIFI;,ATIONS OF 310 CM 1r.2"(3 ,
13. PUMP AND. FILL ANY EXISTING CESSPOOLS. REMOVE ANY ;LOGGED SOIL, BLOCK, ANC' `.:)TONE IN
BENCH MARK--TOP' OF MAG LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT. DEPTH (inches) ELEV,(feet'j
NAIL= ,',.,;'>,7Ci f �I�;±r:,E;' '14. ALL CONSTRI_ICTION TO MEET TITLE 5 AND LOCAL REGULATI INS.
TEST HOLE [DATE: "' t r 4 r', 1 Y A layer 1: yr 3/F, 4`'6
37,8 CI?e 2�.tJ.. sandy loam
PERFORMED BY: Ron r`;:r,.;lill<,r;, S,'<it Evnl;a<ator 13"
® 40.08 WITNESSED BY: Lee A. McConnell, Inspe, ,.:tor 0 r
�� ' FIE RC, RATE: <2' ,,." �1,, B layer 1 oyr ..>/Y
�... '-t,i;,, I rl I` 'tom`, n ��' I�rayer/ sandy I,,•a n
P/N �'' 39.47 40.51 R'ED C E GRADE BY 7" ON SOIL S!!RVEYi 1 f�;:3.'1;i: {.,arver ,-;r,,rrK e >,;.ar c� 33"
ED 0 70 9.16 SOUTH SIDE OF LEACHING. GE0LO:-1C, MAP(1986'. Barnstable ploin (.Iei�osits ''".8
Invert :,
L
98 Invert 39.20 >,u
/N T40�41 Exist. Cast Iron±
Use Gos Baffle 2 DRY WELL: C layer 11 yr 5/6
Invert 38.73 loomy ,.,Worse sor,d
39,11 .83 2„ Proposed Top Conc.=39.4 (110% grovel'
' x 39 7 � N/F .. I Ic,=.I/4"/ft. / :�/ aAFS pea<>t.,ne=3y,1
7 . �''° Invert .'..:::;.4F ;;•. ( c11. S='1 4 ft T
2 gyp, .GRIFFIN 1 .�c
x � no water
40:2 7j�0, 41 4L1 42.1 F'r;,,F,,�:>ed -� 141"
� a I 44„
�' `� LOT T C) I T
40,6 2 Invert .'....5. ?� t 3 Q 36.E
�p �''°q'� Inver .E;,;1
�7,715(" S.F. '� 41: ' I 6" �'t t)t: ot, .`'t'Y`l�:i�..a r�:� Proposed F'r tip o*;ed � ��• Pottorn
41.9
42.0 x 40:8 �4 � lV a
41 N/F x41.8 Bottom TH1=3, .0
<
LITTLEFIELI - 3 41:8 6 ::. ... �� N GPI AT 1
/F
ELDREDGE
ru o E 2:3 BEDROOMS:
2:4 T1N > H X GARBAGE GRIN[.`ER: N, LEACH AREA
N . �,t / REQUIRED,r ' c` r !.! BETWEEN
{�?_ REQ IRED, AP CITY: 33 GPC:' •:;E 2 [ RY WELLS WITH 4
42.4 , ,� r� , ' �,, r
b=t7> tY; SEPTIC TANK: 1,.1:,C, GAL. THEM AND 3 .,,F TONE ON THE SIE'ES,
�nf � BOTTOM LEACHING AREA: 314.1 SF AND 4' OF `:;Ti'DNE ON THE ENDS, Ff-)R
> „
BENCH MARK--TOP OF WO.;C �42.40 43.0 ? ' X 1t',U3';] A L`.'Nr E?Y� i;..a -'ii WIPE BY
STAKE= 42.4; 'GIB±(,r $ x 42.0 *a>C IC'E LEACHING AREA: CDEEF' LEACH AREA.
TH 1 42.6 [2(1C.I.B3' F 2I') X 2' [.EEF'i] :F
4 .6 ari 3.1 [E`IGN CAPA+:;ITY: 350 GF'[D
[(314,1 SF + 1519 3 SF) X .74 GPD/SF]
4 1 EXISTING SYSTEM BELIEVED TO
4 .3 BE TWO CESSPOOLS--IF 1 0,j
GALLON TANK EXISTS, USE IT,
3,
x p RESERVE
J2 3.
C
x 4.6 r•
43.$ �_43, BENCH MARK-- >.E. CORNER OF
CD BLOCK= 42.7.1 (r, Cs.B'
(BLOCK UNDER POST NOT AT CORNER LAr'N,'INC)
77. 0, <
N/F S 79+ �' �e 44,9
NICKERSON �9.70 N/F
DONNELLAN
SITE PLAN
N/F FOR
REILLY THI;:> F=LAN IS: A VALID, �::,' F'Y ;"DNLY IF IT BEAT;{
AN t"::RI INAL F'E() STAMP) AND `tit NAT1,..IRE. M C)" R I S E')` C'N" N T E I N
°FMAss � . "°Ms � LOT 1 , €3 PIPOINT �I T ILL MA
LEGEND
a! Jgcy > ' � oNALD,cy�s`. a
TH 1 TEST HOLE LOC:ATI1DN, NUMBER � 0 � � §� ,, �: U T � � � 1 ¢� L 1
# 1060 >
W WATER LINE MARKING` � .• �, #31/79 �
E OVERHEAD- ELECTFRIC WIRE`s tIF SHCDWN �` �`�c�sTER�` �' " C °�Ess�°tee
x 9.5 x EXISTING & PRO'POSECD ELEVATIONS 'X' MARKS POINT`; ���„sq ��N � �v��o sURNJ
€I.7 . NI TAR �`�
O
EXISTING CONTOL IF,' �' v . „ � �1 H
t 2Z �. LC J. �.AGILL �, PLS, RS
/ 8® F'R;,'F':,,sSECJ .,,;NTOI_!R PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN
l.!TILITY PULE (IF SHOWN; P.O. BOX 258
1B EXISTING [DRAINAGE CATCH BASIN f
x - FENCE (;IF SHOWN, NOT ALL `:SHOWN; �l C)( WEST YARMOUTH, MA 02673
TREE `.IF ;-HOWN, NOT ALL SHOWN) HEALTH AGENT APPROVAL DATE �5051 77 3-9700
2; "`1 BY R.J. C"A[ ILLA;; F'A'..=E 1 ?F 1