HomeMy WebLinkAbout0305 RIVERVIEW LANE - Health 305 RIVERVIEW LANE, CENTERVILLE
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UPC 12534
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diipnsal Works Tnnitrnrtion ranfit
Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal
S st
67
...- •-• ..
.--••-
oc o Addre t No.
—- er . ... • `.-----•------•---•..............................
W � -- Address
Installer Address
U Type of Building Size Lot._��.? .....Sq. feet
Dwelling—No. of Bedrooms____.____ ...........Expansion Attic ( ) Garbage Grinder ( )
� Other—T e of Buildinl _
a yp g No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures -------------------------------------
Design Flow.................//0..................gallons per per day. Total daily flow............ Q._.................gallons.
W W Septic Tank—Liquid capacitylW.bgallons Length................ Width................ Diameter................ Depth..............
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing nk )
'—' Percolation Test Results Performed by..../ _ __ --- _.......... Date.___-
,----f--
,� Test Pit No. 1....4 ..minutes per inch Depth of Test Pit.___la....._... Depth to ground water--_- ON
�Z4 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
04
--------- --------------------------------•----...-----........_..•-•---------..........................................................
O Description of Soil L.%' - 1- C. �'t•-------••------------------------•-------------------------------------------------------------------------
V -----------------------------------------------------------------------------•---•-----..._...--------------------------•----------•-------------------------------------...-------•-------....---------
W
x -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
--------------------------•---------.------------------------------.....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliple has been issued b the board of health.
Signed .. ''.......... . ! .
Daze
Application Approved By .............. -- ------------------------------------------------------------------------ ...........ff.....
Date
Application Disapproved for the o nowingreasons• -------------------- ---------------------- -- -- -- ------------ -- ------------------ ------ate..--..................
----------------------------------- ------------- -- -- -------------------------------- ---------------- -------------- .......................---------------------------------- ------- ----------------- - ----------------
Date
PermitNo. .. .a....-....... .................. Issued --------------------............................................
Date
No.....L.a.:. .y FEB........d. .......
THE COMMONWEALTH OF MASSACHUSETTS
` .BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Mgpaaal Works Tnnitrnrtion rumit
Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal
System at: _
-- - Q. .l Cf � .....
.......•... ........ ..... ._...... ._.... ...--•.-•--- •... _....._.....
/�Locat one�Addres[s� jn- - ---
- --!`�;_-_-=---•`--- .......::: ---------- -----•-------•-- •-•-•-- Lot No ..............__
Owner l/f_ Address
Installer Address
Type of Building Size Lot...�_�'_t_�A�....Sq. feet
1—, Dwelling—No. of Bedrooms............?..............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building & t "49o. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .......................................7'...�C.......................................................................................................
W Design Flow..................r��......_........__gallons per person'per day. Total daily flow............._....._....__..................gallons.
W Septic Tank—Liquid capacity./!VPgallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---_--------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----- ..... .............................. Date.........................................
Test Pit No. ..... .minutes per inch Depth of Test Pit------/0...__... Depth to ground water_.__.
gZ., Test Pit No. 2................minutes per inch Depth of Test Pit-_______-----__.---- Depth to ground water........................
-----------------•----•----------•-----•-----....----.........•---........................................................
0 Description of Soil-----f...G���P/1. 11wtd.-------------------------------•-•------------------------------•--------
x
Z -----•--•---•------------------•----------•-----------•-------------•-----•-.....------•------------------------•--------------•-------------------------•-••-•-•--•----•--------------......--•--_...--
U Nature of Repairs or Alterations—Answer when applicable.___............................................................................................
----------------------------------•-----------------------•---•---•------•-•------•-.------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed -------- ------ ------------------ ------ .......................... ------------
Dare
Application Approved B g
PP pP Y .............. r,-,..",.w.'---------------------------------------------------------------------- _.. ... -oZ
Date
Application Disapproved for the fo lowing reasons- -----------------------
. -------- -------------------- ----------------------------------------
g � Date
PermitNo. - `�.1..... '----------------- Issued ------------------------- -. ..---......--------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE r
C1elrt#iftett#e of CEumlatianre
T IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X ) or Repaired ( )
by � � ��� ........... ---- -- ----
i 1 �J JrD / 'V In/,_ 'tale^
at ------------------------------------------------------------------------------------------------------ ----------------------..............-------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 The St t Environmental Code as described in
the application for Disposal Works Construction Permit No. ----.-..a.- .-- .
-- ..... dated ------- -- --------- ------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.DATE...------/ � Y Inspecto' L.r ..............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.... FEE........................
Disposal Work.5 Tnnitr #ion rrmit
Permission is hereby granted_. --------------------------------------------------------------------------------------------------• ........
.......
.....--------
to Construct X) or Repair ( ) an In/d�iviid/ual ewage Disposal S-_y_ste,m. ' q
at No.. D :/ P
Street
as shown on the application for Disposal Works Construction Permit No,__.._.___,...______ Dated..........................................
--------•-----------•------------------------------------
f ................................
_--•-•........................ Board of health
DATE..................
. 1
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
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DATE:_ 8/6/99____
PROPERTY ADDRESS: 305_Riverview Lane
Centerville ,Mass .
------------------------
02632
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon septic tank .
2 . 1—Distribution box .
3 . 1-1000 gallon precast leaching pit .
Based on my inspection, I certify the following conditions:
4 . This is a title five septic system. ( 78 Code )
5 . The septic system is in proper working order
at the present time .
6. Waste water is 49" below the invert pipe
of the leaching pit .
SIGNATURE: f _J
Name:—,L, P _ Macomber _Jr �� 1 9 e
Company: Joseph_P . Macomber_& Son , Inc .
y
Address: Box—6 6------------- AUG 2 3 1999 S
Centerville , Ma ._02632-0066 ,
Phone: 508_775_3338ro
_______ $ £ �
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
LOSEPH P. MACOMBER & SON, INC.
anks-Cesspools-LeachfleldsPumped & InstalledTown Sewer Connections
66 Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUDY Cox
Secrer.a
ARGEO PAUL CELLUCCI DrwID B. sTRI'h'
Corr_s.s:o�
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Addrazs: 305 Riverview Lane Nam@ of OwrwJohn Bowes
entpprvi11e ,Mass . 02632 Ad&e."of Owrw:
uau oflnspoc son:
Name of Inspector:(P+aase PrirOJ Joseph P. Macomber Jr.
I am a DEP approved systans Uupoctor purwam to Section 15.340 of Tide 5 (310 CMR 15.000)
cornpanyNanse: Joseph P Macomber &son. Inc.
Wb1ngAd&—: 2632-0066
Telephone Numb,ef 0 R 7 S 33 3 8
CFATIFICATION STATEMENT
I csrtify that I have personally Inspectsd the sewage disposal system at this address and that the Information reported below is true, sccurate
and complete as of the time of Inspection. The Inspectlon was performed based on my training and experience in the proper function and
maintenance of on•site se age disposal systems. The system:
. Pesses
_ Conditionally Passes
_ Needs Further Eve stion By the Local Apyroving Authority
_ Fei s
inspector's Sigrtav,sre:
Date: w/
The System Inspec shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)wfthin thirty 1301 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 ohEnvlronmewal Protection. The original should De sent to tnt
system owner.and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Psee I of 11
�, Primed On itacycl.d Paper
_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:305 Riverview Lane
Owner: John Bowes
Dav of In:pectkmB/6/9 9
INSPECTION SUMMARY: Check A, B, C, of A
A. SYSTEM PASSES:
I have not found any information which Indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure
77 criteria not evaluated are Indicated below.
COMMENTS:
S. SYSTEM CONDITIONALLY PASSES:
-AllL 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 ys no, or not determined(Y.N, or NO). 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 complying septic tank as
approved by the Board of Health.
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).
broken pipes) are replaced
obstruction is removed
distribution box Is levelled or replaced
- The system requfred pumpirfg-na»than'fourtimes a yeardue to broken or obstructed pipe(s). The ryatam wilFpesr--
inspection if(with approval of the Board of Health): -
broken i e(s) are're laced
DP P
obstruction Is removed
• 4
4
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
propertyAddress: 305 Riverview Lane Centerville ,Mass .
Owner: John Bowes
Date of Inspect'«,:g/6/9 9
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 WTTH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING W A MANNER WHICH.WILL.PRQTECT THE PUBLIC tfEALT1iAND SAFETY AND THE ENW. BONMENTs
�3 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.
within 50 feet of a private water supply well.
tank and soil absorption sys
tem and the SAS is wit P
The system has a septic t P
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 pre rice of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
Al.
�YIJ
revised 9/2/98 Page 3orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
P,opertyAddre1:305 Riverview Lane Centerville ,Mass .
own": John Bowes
Data of Inspection: 8/6/9 9
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
etertt component due to an overloaded or�legged'SAS or cesspool
Backup of•sewage ir,toiecility"or . --�-'
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 di�tribut)V4x above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in coaepvol Is less than 6" below Invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped 1.
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 60 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. 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:
.14 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 i
�// the system is within 400 feet of a surface drinking water supply
J_ .I the system•is-within 200(aetof•o-tAbutery-We*urfao"6rk4w9•w8ter•cupPly ••• - ---
_ _A 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 15.304(2). Please consult the local regional
office of the Department for further infor nation.
revised 9/2/98 Page 4orII
r -
I
j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 305 Riverview Lane •Centerville ,Mass .
Owrw: John Bowes
Date of Inspection: 8/6/9 9
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
-None of the system-con*ostants kawa)een puPNwd4Qr-&,Jeast trwoawaeka aadtbe system hasbaeawcaiaiwgwss+rsal Jlow
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.
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,4luding 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 orrthe site has been determined based on:-
Existing information. For example, Plan at B.O.H.
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)1
7 _ _ The facility owner.(and.occupants..if diffaraw from owiner),�uere prnvidad.�uith infnrmzWoann thA prnpar rnAiataa&& ... ..f
Subsurface Disposal Systems.
� s
i
i
i
II revised 9/2/98 Page sorn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddre": 305 Riverview Lane Centerville ,Mass .
Owner: John Bowes
Date of Irupection:8/6/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow:�_g.p.d./bedro
Number of bedrooms(design : Number of bedrooms(actual):
Total DESIGN flow
Number of current resident
Garbage grinder(yes or no): 5
Laundry(separate system) ( es o no :_;. If yes,se pacate Impaction.required
Laundry system inspected a no)
Seasonal use(yes or no): el
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no) WX
�iA� t-1• l�
Last date of occupancy: � b%yti0e �1�
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow: AM Q P d ( Based on 15.2 3)
Basis of design flow
Grease trap present: (yes or no)-
Industrial Waste Holding Tank present:(yes or no) � JJ//
Non-sanitary waste discharged to the Title 5��m: (yes or no)&T
Water meter readings,if available:
Last date of occupancy: /Y
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RE RDS and ource of informati n:) • / GfO I �� ,
System p
umped as part of i spaction- (yes or no) ll
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF YSTEM
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 4.4 Copy of DEP Approval
Other Ad
AP MATE AGE of all components, date installediif known)•and source of-information:
Sewage odors detected when arriving at the site:(yes or no)/
s
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAd&a.": 305 Riverview Lane Centerville ,Mass .
Owner: John Bowes
Data of Irtspeat -8/6/9 9
BUILDING SEWER:
(Locate on site plan)
Depth below grads:
,j,��
Material of construction:„_cast Iron PVC_other(explain)
Distance fro rivets Water supply well or suction line d� —
Diameter
��r
Comments:(condition of Joints,venting, evidence of leakage,-etc.)
Joints aDDear.
SEPTIC TANK
(locate on site plan) ��
Depth below grade:��rt�i+
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explaln)
If tank is Enetal,list age_ 1s.age.conrwmad by Certificate of Compliance_(Yes/No)
i / / rr d rw
N
Dimensions: b A7 4
Sludge depth. � ••Sludge
Distance from top oO/f�E�ss lu . to bottom of outlet tea Orbatfls:�i
Scum thickness:-Gam
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bOnOff of outlet a or baffla:�
How dimensions were determined:
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or-baffles,-depth of liquid level In relation to outlet invert, suuctura+integrity,
evidence of leakage, etc.)Pump tank AnnU& .Tn 1 at R n„t 1 of- t-o®g
are in place
isposal present .~
GREASE
(locate on site plan)
Depth below grada:A)lf
Material of consuuc on;40concrete4met&LdFlberglassA�/•Polyethyleneo✓�other(explain)
/
Dimensions: �
Scum thickness:
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of s um to bottom of outlet tee or baffle:.4,9
Date of last pumping:
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.)
Grease
s
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropenyAddrass: 305 Riverview Lane Centerville ,Mass .
Owner: John Bowes
Data of trupection:8/6/9 9
TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time of, Inspection)
(locate on site plan)
Depth below grade:
Material of construction/NRconcrete/metal�Fiberglasst/RPolyethylene/gother(explain)
AW
Dimensions: AU
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm In working order:Yes4//9 No&4
Date of previous pumping: All
Comments:
(condition of Inlet tee, condition of alarm and float switches, etc.)
Tight or holing ran► Q aro slot Present . -
DISTRIBUTION BOX:,
(locate on site plan)
Depth of liquid level above outlet Invert:_
Comments:
(note•if level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) — - —
Distribution box has one lateral-No Pvidpnrp of sounds
carry over No evi dPnrp of l pnknge int-0 or- e�t; e€ the Lea;
PUMP CHAMBER4ke,
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms In working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
ump c amber is not present -
revised 9/2/98 Page 8of11
t % ^4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddreu: 305 Riverview Lane Centerville ,Mass . 02632
Owrw: John Bowes
Dau of Inspection: 8/6/9 9
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries,number:_ m
leaching trenches,number,length:
leaching fields, number, dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology: (�
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to medium fine ganrl Na s; s;s of hydFaulie fa�!Ur_
CESSPOOLS:
(locate on site plan) ,,qq
Number and configuration: V
Depth-top of liquid to inlet invert:
Depth of solids layer: AIA
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of Inspection)
Cesspools are not present _
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding,condition of.vegetation, etc.)
Cesspools are not prpgi-nt
PRIVY:41-
(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.)
rivy is not present
r '
4
revised 9/2/98 Page 9of11
_ SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
SYSTEM INFORMATION (c0n*X;0d)
PrcpanyAddrss: 305 RiveTview Lane Centerville ,Mass .
0wrw: John Bowes
Dauof""cd—:8/6/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include tles to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where publlc water supply comes Into house)
1
5 V er v,e >✓ N CepT-erg)l)e
ac I<
5 �
J �
s
revised 9/2/98 Pap 10oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
p,.,p.rtyAd&"s: 305 Riverview Lane Centerville ,Mass .
Owner: John Bowes
Data of Inspection: 8/6/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater:rW Feet
Please indicate all the methods used to determine High Groundwater Elevation:
jbtained frm Design Plans on record
bserved.Site (Abutting property observation hole, basement sump etc.)
Datermin,doftom local conditions
Chocked with local Board of health
Yecked FEMA Maps
Chocked pumping records
Checked local excavators, Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used Gahrety & Miller 1>144- .
12/16/94
s
V4�
revised 9/2/98 Page 11of11
r
J.
, •rrsnTr.—nIT�'.9'T�aeRrIn•wtrwerTnrnsanarn-.e+wzre�anr+ewT nerw�u�•r�rt•� .t-n�-rr.arn—'..-.r...�
1 TOWN OF Barnstable I10ARD OF HEALTH +
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
-•TA1••••::a—r.17.-.>•TTJnT.'1.1'R.T'i TIT'lRl/T�T:rt1-'{RR'�trRw/-•TA/tAI t7 tnnn .+Sr 1'T• +-1• •�..^
-TYPL OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 305 Riverview Lane Centerville ,Mass . '
ASSESSORS MAP, BLOCK AND PARCEL #
I
OWNER' s NAME John Bowes,
.m�
PART D - CEI?TIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P•Macomber & Son -Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE (508 1 775 - 3338 FAX ( 508 ) 790-2578
R
CERTIFICATION STATEMENT -
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Chec one :
System PASSED
The inspection irhich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have conc�icted has found that the system fails to
Protect the jitiblic health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this ins�secti n form .
Inspector Signature L. Date (?
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF IIZAL1'1I:
If the inspection FAILED, the owner or..`operator shall u d
within one year of the date of the inspection , unless allowed ort required
he m
otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
L
TOWN OF B STABLE
LOCATION, SEWAGE #
r JnLLAGE e�g c ASSESSOR'S MAP& LOT
` ;.[NSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACII:ITY:.(type.) /t�G�� �� (size)
i
NO. OF BEDROOMS `
r
BUILDER OR O -
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of,Wetland and Leaching Facility(If anywetlands exist
within-300 fee of ac - g facili Feet
Furnished by
)'Vey V,eV t A) Ccyv7"e,vl/)e
30
ti
-3 C.
� l TOWN OF BARNSTABLE 7
LOCATION (7� �C� +S Rl',Xcv�- v LO kn SEWAGE # ,`r
VILLAGE Cew,t (J 1 ASSESSOR'S MAP & LOTT' OT f a
IASTALLER'S NAME & PHONE NO. '3 1 0i"0 DPI -7?1-logo
SEPTIC TANK CAPACITY I,DOU ,it IAS
LEACHING FACILITY:(type) I�w�` Q'� (size) 6 00g4(w�S
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER �a�/S�c� �7;}���,�� �D. 77I�cr6
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: �-
VARIANCE GRANTED: Yes No L�
,95
,9`� � � ^
.����
fie" �� .
�� ah
�o� �D + �l
:ro{ ,;
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
21ppliLation for Disposal *pBtem Construction Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.�a
Assessor's �
Ma /Parcel
P ZiS -� E9�t 1 t� aes 2_
Installer's Name,Address,and Tel.No. —� �,� - Designer"S'Nam/ey,Address,and Tel.No.
to
Type of Building:
Dwelling No.of Bedrooms Lot Size I1'r20Ot- sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date 20 Number of sheets Revision Date'
Title O—30Y-
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: �L� 2p ici
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 Certificate of
Compliance has been issued by this Board of Health.
Signed Date 30 i
Application Approved by Date /
Application Disapproved by Date
for the following reasons
Permit No._ = (�f�- Date Issued
No '�/ t TT Fee
THE COMMONWEALTH OF MASSACHUSETTS Enteredincomputer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
apphLation for -misposar *pstrm ConstrULtion 3permit
Application for a Permit to Construct( ) Repair('-' )-..Upgrade( ) Abandon( ) ❑Complete System Edndividual Components
Location Address or Lot No. a f 4, Owner's Name,Address,and Tel.No.
%
Assessor's Map/Parcel `2?.£i 91 ;�%a� ;Z» �A��` j>rip
Installer's Name,Address,and Tel.No. ��rr- +7. � C Designer's Name,Address,and Tel.No.
f y�j Gcrr>n rr..ai�...y t t�•1 f1"#'a'�1�,(t'�,'-•
Type of Building:
Dwelling No.of Bedrooms Lot Size I ,?eac�f sq.ft. Garbage Grinder( )
. Other Type of Building ( No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) r��� gpd Design flow provided �'V �,�, gpd
Plan Date C1 3r O t
Ci Number of sheets Revision Date
Title T-)- %30'A-
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
ty
Date last inspected: 5PO t AMke� Z o►9t
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 Certificate of
Compliance has been issued by this Board of Health. {�
Signed! ) C `_ Date
Application Approved by 1_._ /-�- -._`-�....-,�' Date ✓�.'�!" /
Application Disapproved by Date
for the following reasons
Permit No. C—Do/ c b' Date Issued
--- -------- --------� ------ ---- -----------_ _--- -------------_ - -- -----= ---=--- ---=- - -- ----=--=--=-- -_- _=- - -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Comphante
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
at :3n -- f L.. .u V��-• xr has been constructed in accordance )
with.the provisions of Title 5 and the for Disposal System Construction Permit No_.—�4V,�3 dated
Installer �11C(,,� ] ./� O XU CO. d� Designer J\ In I�y
#bedrooms A � / / f Approved design flow A �y I gpd
The issuance of this petirrtrt hail not be construed as a guarantee that the system wil functiion)as;designed. c
Date b r, Inspector `
it
-- I-/---------------- --------- ---.-------
No: q Fee .
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
MispoSal 6pstem ConBtrUthon Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( )
System located at 305 V-@✓L V
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must�l e completed within three years of the date of this pew rmit.
Date I /, /'! Approved by,,_ •�.
Commonwealth of Massachusetts
Title 5 Official Inspection Form �>
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1e
iv
305 R' erview Lane .y
Property Address
Sally Glista
Owner Owner's Name /
information is
required for every Centerville �/ MA 02632 10-2-19.''
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.
OF Ud rrnii�kt
''mng out ormsen A. Inspector Information 6 _� ` 9�y,
on the computer, a��t •JA M E S u'
use only the tab James D,Sears = �,
key to move your Name of Inspector
cursor-do not Ca ewide Enterprises
use the return Company Name [ ••. •''G�
key. F �.
153 Commercial Street �y� s�S�Q
Company Address
VQ Mash pee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); I have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
a_m'-j— 10-2-19
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: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.
15insp.doc-rev.7126'2018 Title 5 Official Inspection Form:Subsurlace Sewage Disposal System•Page 1 of 18
a5ed xed dH 6 V£6 6 60Z CO 100
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
5
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
y 305 Riverview Lane
Property Address
Sally Giista
Owner Owner's Name
information is required for every Centerville MA 02632 10-2-19
page. Cily/Town State Zip Code Date of Inspection
C. Inspection Summary ,
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes-
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal,Tank D Box and pit.
2) System Conditionally Passes:
❑ One or more system components as descrlbed 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..
t
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):
tNnsp.cioc•rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18
Z a6ed xed dH 1,1•:£6 6 60Z £0 100
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
IM is
requiredaired for every Centerville MA 02632 10-2-19
for
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below):
t
❑ 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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
3) 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.
a. 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:
t5insp.doc•rev.7/2612016 Title 5 Offidal Inspection Form!Subsurface sewage Disposal system•Page 3 of 18
£ a5ed xed dH 6 6:£6 6 60E £0 100
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
Information is required for every Centerville MA 02632 10-2-19
page City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) 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
t5insp.dcc rev.7126/2018 Title 5 Official Inspection Farm',Subsurface Sewage Disposal System-Page 4 of 16
t, abed xeJ dH 6 6:E 6 6 60Z £0 V)0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
information is required for every Centerville MA 02632 10-2-19
page. City/Town State Zlp Code Date of Inspection
C. Inspection Summary (cont,)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in P, a now is less than 6"below invert or available volume is less
than 1/7 day flow R/r
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd,
❑ ® 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.
5) 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 C.4.
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
15insp.doc•rev.7126t201e Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 5 of 16
C abed xeJ dH 6 6:£1• 6 1,0E £0 100
Commonwealth of Massachusetts
1 Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
!y' 305 Riverview Lane
`�� Property Address
Sally Glista
Owner Owner's Name
Information is required for every Centerville MA 02632 10-2-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat,or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
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 NIA)
® ❑ 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)]
t5lnsp.doc,rev.7126/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 18
9 a5ed xe j dH 6 6:E I. 6 602 EO 1D0
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
305 Riverview Lane
.w Property Address
Sally Glista
Owner Owner's Name
Information is required for every Centerville MA 02632 10-2-19
page, Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
1000 Gal.Tank D Box and pit.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, If available last 2 ears usage 2017-73,000Gals
g ( y g (gpd»' 2018-61,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
t5insp.doc rev.7,26f2018 Title 5 official Inspection Form:Subsurface Sewage Dleposal System-Page 7 of 18
L a5ed xed dH 2 6:£l 61.0E £0 100
i
Commonwealth of Massachusetts
,if Title 5 Official Inspection Form
(/i$ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4'
305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
information is required for every Centerville MA 02632 10-2-19
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/person s/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
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 below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7f28/2018 Title 5 Olfici al Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
g a5ed xe� dH 2 6:£6 6 60Z £0 ADO
•N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
305 Riverview Lane
V Property Address
Sally Glista -
Owner Owner's Name
information is required for every Centerville MA C2632 10-2-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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/Altemative 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
❑ Tlght tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
NA 2019 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth belowgrade: 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.):
Pipeina is 4" PVC SCH - 40.
i
151nsp.doc rev.7,2612018 Title 5 Of del Inspection Form:Subsurface Sewage Disposal System-Page 9 of to
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Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
information is required for every Centerville MA 02632 10-2-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
6. Septic Tank(locate on site plan):
Depth below grade: 10"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 cf certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle 28
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tank at working level.Tank and inlet cover at 10"w/outlet cover at 4". In and outlet baffle's. No
sign of leakage or over loading.
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 10 of 18
0 6 a5ed xed dH U£l 61,02 £0 130
Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r305 Riverview Lane
Property Address
Sally Glista
Owner Owners Name
information is required for every Centerville MA 02632 10-2-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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.):
8. 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: aeons
g per day
t5insp.doc-rev.7f26=18 Tltle 5 Official Inspacllon form:Subsurface sewage oisposal System•Page 11 of le
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Commonwealth of Massachusetts
VTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11
� 305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
information is required for every Centerville MA 02632 10-2-19
page. Clty/Town State Zip Code Date of Inspection
D. System Information (cunt.)
8. Tight or Holding Tank (cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note If box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box,etc.):
D Box is 16"x 16"A6" below grade w/one line out. Box is new 2019 w/cover at 6".
t5insp.doc•rev.N2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 12 or 18
z l abed xed dH 9 6:£6 6 V £0 100
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
informationis
requiredairedfor every Centerville MA 02632 10-2-19
for
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.):
` If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan,excavation not required):
If SAS not locatedexplain wh, :y
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.MS(2018 Title S Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 19
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
305 Riverview Lane
Property Adcress
Sally Glista
Owner Owner's Name
information is required for every Centerville MA 02632 10-2-19
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
11. Soli Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. precast pit. Pit at 3r below grade w/cover at 10". Level in pit at 20"below
inlet. No sign of over loading or solid carry over. No high stain line
12. 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,):
t5insp.doc-rev.W2612018 Title 5 Otfidel Inspection Form:Subsurface Sewage Disposal System•Page 14 of 16
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.cL� Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
305 Riverview Lane
Property Address
Sally Glista
owner Owner's Name
information is required for every Centerville MA 02632 10-2-19
page. aty/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t&nsp.cfoc•rev.712612016 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
information is required for every Centerville MA 02632 10-2-19
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
14. 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
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15insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
305 Riverview Lane
Property Address
Sally Glista
Owner Owners Name
information is required for every Centerville MA 02632 10-2-19
page. City/Town State Zip Code Date of Inspedion
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells N
0
P fh 9 9 2t
Estimated depth to hi h round water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting propertylobservation 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;
Abutting area drop's off 20'+. Bottom of pit at 9' below grade.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15insp.doc rev.712812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 or 18
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Commonwealth of Massachusetts
Title 5 official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y
305 Riverview Lane
Property Address
Sally Glista
Owner Owner's Name
Information Is required for every Centerville MA 02632 10-2-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Cert'rficaticn: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc rev.7,2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 18 of 18
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