HomeMy WebLinkAbout0060 RIVERVIEW LANE - Health 60 Riverview Lane, Centerville
VCLEO
UPC 12543
No.53LOR co
HASTINGS• MN
RECEIVED
COMMONWEALTH OF MASACHUSETTS S E P 2 2 2000
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS TOWN OF BARNSTABLE
DEPARTMENT OF ENVIRONMENTAL PROTECTION HEALTH DEPT.
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT
Address of Owner: BOX 1002 CENTERVILLE MA.02632
Date of Inspection: 9118/00
Name of Inspector: JOHN GRACE
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT t
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 inspection:The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:
�, Date:9/18/00
The System Inspector shall s mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If he 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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION'RECOMMEND PUMPING THE SYSTEM EVERY�TWO RA S R PROPER MAINTENANCE.
S EP 2 2 2000
TQIVNOFSAANsTMIP fi
ir'E�,TN DF-Pr. r
., j
4
revised 9/2/98 Paoe 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 110228 P078
Name of Owner BURNETT
Date of Inspection: 9/18/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y, N,or ND).Describe basis of determination in all instances. If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the
septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure
is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved
by the Board of Health.
nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
due to a broken,settled or uneven distribution box.The system will pass'inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
nta The system required pumping more than four 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
revised 9/2/98 Paoe 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT ,
Date of Inspection: 9/18100 q';'
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 the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I.-
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well',unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution,from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nla (approximation not valid).
3) OTHER
nla
-r
revised 912/98 Paae 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT
Date of Inspection: 9/18/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health
and safety and the environment because one or more of the following conditions exist:
u.
Yes No
X the system is within 400 feet of a surface drinking water supply
' u
X the system is within 200 feet of a tributary to a surface drinking water supply
rr
_ X 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of
the Department for further information.
revised 9/2198 Paoe 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM 114SPECTION FORM
PART B
CHECKLIST
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner: BURNETT
Date of Inspection: 9/18/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
X _ As built plans have been obtained and examined.Note if they are not available with N/A.
X - The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material
of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site
has been determined based on:
X _ Existing information,For example, Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 1 5.302(3)(b)]
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2/98 Pape 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT
Date of Inspection: 9/18/00
FLOW CONDITIONS
RESIDENTIAL
Design flow: 110 g.p.d./bedroom ?{
Number of bedrooms(design): 4 Number of bedrooms(actual):n/a
Total DESIGN flow: 440 gpd
Number of current residents: 1
Garbage grinder(yes or no): NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no): NO
Water meter readings. if available: n/a
Last date of occupancy: n/a
OTHER: (Describe)
n/a
`.`GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no): NO
If yes,volume pumped n/a gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1996 PERMIT 96-294
Sewage odors detected when arriving at the site:(yes or no), NO
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
revised 9/2/98 Paae 6 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT
Date of Inspection: 9118/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 12"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
9
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 6"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1500G L 10'6"H 5'6"W 5'8""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 1"
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: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.) -
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIF
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: nla
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
n/a
revised 9/2198 Paoe 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM I:SPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT
Date of Inspection: 9118/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: nla
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Paoe 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT
Date of Inspection: 9/18/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
1
If not located,explain:
n/a
Type:
leaching pits,number:(n/a)n/a
leaching chambers, number: (n/a)n/a
leaching galleries, number: (n/a)n/a
leaching trenches,number,length: (1)80
leaching fields, number,dimensions: (n/a)n/a
overflow cesspool, number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH TRENCH APPEARS TO BE FUNCTIONING PROPERLY.THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY IN
LEACH AREA.
CESSPOOLS:
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: nla
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic,failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: nla
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2/98 Paoe 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT
Date of Inspection: 9/18/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
9
�•l I�
C
ac- o
,afl;
PA
Ads
Ac1N�
146
�z a�
revised 9/2/98 Paoe 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 60 RIVER VIEW LANE CENTERVILLE, MA 02632 M228 P078
Name of Owner BURNETT
Date of Inspection: 9/18/00
NRCSReport name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators, installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
UGSS MAPS AND CHARTS-10+FEET
r.
revised 9/2/98 Paae 11 of 11
Ps
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF I . . Ir CE�VE8 ,.
NOV
DEPARTMENT OF ENVIRONMENTAL PROTEC ION 7 1991
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 rO� �Hp pTgB(E
WILLIAM F.WELD (J► COXE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
60 Riverview Lane
Property Address: en e v e Address of Owner: Bruce Stewart
Date of Inspection: �a_ Z-�—_T°7 (If different)
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Service
Mailing Address: PO Box 1089 ; Centervillp., MA 02632
Telephone Number- 5 0 8 7 7 5 T R 7 7 h
CERTIFICATION STATEMENT
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-sit:Zp,aysses
ge disposal systems. The system:
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: .. Date:� 7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
YSTEM 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.
Indicate es, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep
£'J Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 60 Riverview Lane Centerville
Owner: Bruce Stewart
Date of Inspection: ��..�,a> 6l -
J SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
CJ URTHER 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 the
public health, safety and the environment.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3 OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 60 Riverview Lane Centerville
Owner: Bruce Stewart
Date of Inspection:
SYSTEM FAILS:
Yo must indicate ei;!,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LAR E SYSTEM FAILS:
You st indicate either "Yes" or "No" as to each of the following:
The f6llowing criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The ow er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 60 Riverview Lane Centerville
Owner: Bruce Stewart
Date of Inspection: �JCS—,ZO-P 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yeses No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
LI/ _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
4 _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 60 Riverview Lane. Centerville
Owner: Bruce Stewart
Date of Inspection: /0—,;a-17
FLOW CONDITIONS
RESIDENTIAL
Design flow:,.?6 O g.p.d./bedroom for S.A.S.
Number of bedrooms:_Z5—e/
Number of current residents:
Garbage grinder (yes or no):Z®
Laundry connected to system (yes or no):yu,�,5
Seasonal use (yes or no):_ZL'� 1995 43 , 000 gals
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no): /i.G 1996 68, 000gals
Last date of occupancy:
COM ERCIAUINDUSTRIAL:
Type of tablishment:
Design N.
w: gallons/day
Grease tra present: (yes or no)_
Industrial aste Holding Tank present-.-(yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water m ter readings, if available:
Last d e of occupancy:
OTHE : (Describe)
Last da of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and so ce of information:
— ,v zo ,t,s I✓/� /L� s a 1`$ Z
System pu ped as part of inspection: (yes or no)_ 61
If yes, volume pumped: gallons
Reason for pumping:
TYPE OFF STEM
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: m
Sewage odors detected when arriving at the site: (yes or no) jL e)
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60 Riverview Lane Centerville
Owner: Bruce Stewart
Date of Inspection: /U—aD— $ -17
B LAU
ING SEWER:
(Locate n site plan)
Depth low grade:
Material of construction: _cast iron _40 PVC _other (explain)
Distanc from private water supply well or suction line
Diamet r
Comm nits: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: oncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: C `� U
Sludge depth: 7 '
Distance from top of sludge to bottom of outlet tee or baffleA �L
Scum thickness: 0 . ' 1,
Distance from top of scum to top of outlet tee or baffle:_ 1
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet ees or baffles, de th of liquid level in relation to outlet invert, structural .i
integrity, evidence of leakage, etc.) ,/�� O /' �� /� tr'�'✓ G e5 sir T11
L
0
GREA E TRAP:
(locate n site plan)
Depth low grade:
Material f construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ions:
Scum hickness:
Dist ce from top of scum to top of outlet tee or baffle:
Dista a from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Comme ts:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integri , evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60. Riverview Lane Centerville
Owner: Bruce Stewart
Date of Inspection: f61 A6—9 7
TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth low grade:
Materi of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dime ions:
Capaci gallons
Design flow: gallons/day
Alarm evel: Alarm in working order_Yes; _ No
Date previous pumping:
Com ents:
(con ion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:V
(locate on site plan)
Depth of liquid level above outlet invert: (�
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
GcJ
` G
PUMP HAMBER:_
(locate o site plan)
Pumps in working order: (Yes or No)_.,,,
Alarms in working order (Yes or No)
Commen
(note co dition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60 Riverview Lane . Centerville
Owner: Bruce Stewart
Date of Inspection: 17
SOIL ABSORPTION SYSTEM (SAS):.
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length: 'z �6 �-
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
/fi
CESS OLS:
(locate n site plan)
Number nd configuration:
Depth-to of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensic ris of cesspool:
Materials of construction:
Indicatio of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm nts:
(note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate o site plan)
Materi s of construction: Dimensions:
Dept of solids-
Comm nts:
(note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60 Riverview Lane Centerville
Owner: Bruce Stewart
Date of Inspection: 10—a0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
V'
s
r,
k
cn ) I
0
0
2
Dv BED
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 60 Riverview Lane Centerville
Owner: Bruce Stewart
Date of Inspection: /0— L0—q -7
Depth to Groundwater 1kFeeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
T-s A/o
(revised 04/25/97) Page 10 of 10
1
Ctl TOWN OF BARNSTABLE
LOCATION F/i J5IP y 4rg" R4 SEWAGE # 61—
VILLAGE L�/1���/i'�I GL�=� ASSESSOR'S MAP& LOT227,v� J,%
INSTALLER'S NAME&PHONE NO. &Z 01, C- e ?P®,0 t/VSe :ZZ6'= 6-7
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) /N5i9 CA1Wd'
NO.OF BEDROOMS
BUILDER OR OWNER _
PERMITDATE: COMPLIANCE DATE: /�ZJ G
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin facility) Feet
Furnished by e+ % cXO!A-1
o -
0()
� a v .
� z
,01
f
r -
No. Fee 4 0 .0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Miggo al *p5tem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
60 Riverview Rd Mr. Stewart
Centerville
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic
P.O. Box 1089
Type of Building:
Dwelling No.of Bedrooms 4 Garbage Grinder(n9
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil sand
Nature of Repairs or Alterations(Answer when appplicable) install a 1 , 500 gal tank, d—box
and Title 5 leachtrench 2x4x80 fill in old cesspools.
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 issued by thd
�akiof Health.
Signed L Date / l�
Application Approved by
Application Disapproved for the folio ing reasons
Permit No. _ ��_ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
h
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS.
Certificate of (tompliance - -
THIS IS TO CERTIFY that the On-sit Se a e Di osal System installed( ) re afired/replaced( X)on
W.E. lobinson 5ep��c S'ery Mr SPe�aart
a � xi`ve�vleWCenterville for has been constructed in accord nce
with the provisions of Title 5 and the for Disposal System Construction Permit No. �l- n"t q dated
Use of this system is conditioned on compliance with the provisions set forth below:
9r 40.00
Fee
THE COMMONWEALTH OF MASSACHUSETTS
Stewart
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi!5poga[ *p5tem.Congtruction Vermit
Permission is hereby granted to W.E. Robinson Septic Sery
1 to construct( )repair an On-site Sewage System located at
60 Riverview Rd Centerville
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
,
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: i l — 9� Approved by �.
a
No. - Fee 4 0.0 0
r
THE COMMONWEALTH OF MASSACHUSETTS ,
- `PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs:MASSACHUSETTS'
0[ppYicatiOri for DigpOgaY. pgtentn O.rY$trUctiOr�r err
t
Application is hereby made for a Permit to Construct( )or Repair(X ),an On-site Sewage Disposal°System.at: t >
Location Address or Lot No. Owner's Name,Address and Tel.No.
60 Riverview Rd Mr. Stewart a
Centerville-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Sept i
4
P.O. Box 1089A
CC y
}
Type of Building: .k
Dwelling No.of Bedrooms 4 Garbage Grinder(flaj
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date ;�•
Title r:
Description of Soil sand ,
7 Nature of Repairs orAlte`rations(Answer when applicable) install a 1 r.�00 gal tank, .d-box
,,, a°rid Title 5 leachtrench 2x4x8D n o cesspoo s.
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-
cafe of Compliance has been issued by this_B�ar f Health. j
` Signed �./ t �(� l� Date �""�"'_ Cs►
Application Approved by' j
Application Disapproved for the follo ing reasons j
j � P
i
Permit No.T/�- y Date Issued a " E 1
3
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I,
hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at �d ✓y�- / w C�J _ meets all of the
following criteria:
There are no wetlands within 300 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED: Gti / DATE: .
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
V
VY
3
L.j
'tea V J O
6 li