HomeMy WebLinkAbout0009 ROSEMARY LANE - Health 9 ROSEMARY LANE, CENTERVILLE
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JOB # 83-162A
CEPTIFIED PLOT PLAN
LOCATION: L- 1 ROSEMARY LN C ' VILLE PREPARED FOR:
SCALE: 1 "=30 ' DATE: 3/21/87
REFERENCE: I `�
LCP 41445A. VALAND INC . ` Pl.
I HEREBY CERTIFY THAT THE BUILDINGS y�
SHOWN ON THIS PLAN IS LOCATED ON THE L,l °
GROUND AS SHOWN HEREON. nj��
BUILDINGS CONFORM TO SETBACK REQUIREMENTS P`�N Of �qS (% /�✓ �Q"
OF THE TOWN WHEN CONSTRUCTED.
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Name of Owner PAUL LOEBER
Address of Owner: SAME
Date of Inspection: 4/6199
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name: John Graci Title V Septic Inspection
Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636
Telephone Number: (508)664.6813
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-site sewage disposal systems.The system:
X Passes The inpection Is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
_ Needs Further Eval ati n By the Local Approving Authority performing at the time of the Inspection.My inspection does
_ Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:417/99
The System Inspector sha submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:4/6/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ 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.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
na 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 yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
na 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.
na 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 pipe(s)are replaced
obstruction Is removed
_ distribution box is levelled or replaced
na 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 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:4/6/99
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 16.303(1)(b)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 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 nta_(approximation not valid).
r
3) OTHER
nta
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:418199
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 n&.
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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
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:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
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 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:4/6/99
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)1
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
s
I
Lrevisedg/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:4/6199
FLOW CONDITIONS
RESIDENTIAL
Design flow:-Q g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):.
Total DESIGN flow: IV
Number of current residents:2
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system Inspected(yes or no).M
Seasonal use(yes or no):JMQ
Water meter readings,if available(last two year's usage(gpd): n/a.
Sump Pump(yes or no): NQ
Last date of occupancy: n&
COM M ERCIAL/INDUSTRIAL
Type of establishment: n(a
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n/A
Grease trap present:(yes or no):JLQ
Industrial Waste Holding Tank present:(yes or no): rLQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:n&
Last date of occupancy: n&
OTHER: (Describe)
Last date of occupancy: n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
NONE
System pumped as part of inspection:(yes or no):W
If yes,volume pumped Wit- gallons
Reason for pumping: xi&
TYPE OF SYSTEM
XSeptic 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&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
I
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 9098 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:4/6/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: IL
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n&
Comments: (condition of joints,venting,evidence of leakage,etc.)
n[a
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nla
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
Wa
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: I"_
Distance from top of scum to top of outlet tee or baffle:-C
Distance from bottom of scum to bottom of outlet tee or baffle: R!
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
n&
Dimensions: n&
Scum thickness: n/A
Distance from top of scum to top of outlet tee or baffle:-n&
Distance from bottom of scum to bottom of outlet tee or baffle n&
Date of last pumping: n&
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.)
n1A
revised 9/2198 Page 7 of 11
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:4/6/99
TIGHT OR HOLDING TANK: MQ (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)
n(a
Dimensions: n/a
Capacity: n1a gallons
Design flow: n(a gallons/day
Alarm present: NO
Alarm level:jjLa_ Alarm in working order:Yes_No_: NQ
Date of previous pumping: 19A
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n(a
DISTRIBUTION BOX: _
(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.)
wa
PUMP CHAMBER: MQ
(locate on site plan)
Pumps in working order:(Yes or No): MQ
Alarms in working order(Yes or No): MQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2J98 Page 8 of 11
- r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'C
SYSTEM INFORMATION(continued)
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:4/6/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Na
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: -nLa
leaching galleries,number: -a&
leaching trenches,number,length: nLa
leaching fields,number,dimensions: n&
overflow cesspool,number: nLa
Alternative system: nla
Name of Technology: jVa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY-PIT HAD V IN IT AT THE TIME OF THE INSPECTION NEVER MORE-
THAN 2•
CESSPOOLS: _
(locate on site plan)
Number and configuration: nLa
' Depth-top of liquid to inlet invert: n&
Depth of solids layer: n&
Depth of scum layer. n&
Dimensions of cesspool: n&
Materials of construction: n&
Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)WA
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
PRIVY: _
(locate on site plan)
Materials of construction:nla Dimensions:n&
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:416/99
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)
n/a
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revised 9/2/98 Page 10 of 11
i
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 ROSEMARY LANE CENTERVILLE MAP 147 PAR 7 LOT 9
Owner: PAUL LOEBER
Date of Inspection:4/6/99
NRCS Report name: nLa
Soil Type: n1a
Typical depth to groundwater: n1a
USGS Date website visited: nLa
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X 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)
USGS MAPS AND CHARTS AND VISUAL
revised 9/2198 Page 11 of 11
Commonwed##h of Mos=huselts John-Grad -
i xecuwe Office of Environmental-Affairs -- -- - --- D:E P. Title V Septic Inspector
- - —_
- P.O Box 2119 i
Department-of Teaticket, MA 02536 _ _--
. Environmental Protection _
(508) 564-6813
IL
^� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM If
S PART ]�
CERTIFICATION
Property Address: 9 RoSeMary Lane,Centerville — Address of Owner:
Date of Inspection:7117196 (If different)
Murphy
Name of inspector:John Gracl
Company Name,Address and Telephone Number:_
_
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-site sewage disposal systems. The system:
x Passes
_ Conditionally Passes
Needs Furth r E luation By the Local Approving Authority
_ Fails
Inspector's Signature: Date: 7117196
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair, passes inspection.
Indicate yes, 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, 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 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
1
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SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION-FORM. -
PART A
CERTIFICATION(cont1nued). -
Property Address 912oseMary Lane,Centerville z -
- Owner: Murphy
Date of-inspection:7117196 -
Sewage backup or breakout or high static-water level observed in-the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the-Board of Health): i
broken pipe(s)are replaced -
obstruction is removed
_ distribution box is leveled 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 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 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
DI SYSTEM FAILS:
_ 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.
Backup of sewage in 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
cesspool.
SAS is in hydraulic failure.
(revised 11/15195)
2
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
PART'A - -
CERTIFICATION-(continued)__.-_-
P-roperty Address: 9 RoseMary Lane Centervllle
Owner: Murphy
Date of Ins.pection:7117196
D] SYSTEM FAILS(continued) - -
_ Static liquid level in the distribution box above outlet invert due to an overloaded nor clogged SAS or cesspool.
Liquid depth in cesspool 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 pipes
------ Numbers 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 1 of a public well.
Any portion of a cesspool or privy is-within 50 feet of a private water supply well. -
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. 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:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flaw 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:
_ 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 owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115/95)
3
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7
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
- PART B -
CH ECLIST -
P ro pe rty Ad d ress: 9RoseMaryLane,Centerville -- _
Owner: Murphy _
Date of Inspection:V17196 -,
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the 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.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
.f.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM —
PART C
SYSTEM INFORMATION -
Property Address: 9 RoseMary Lane,Centerville
--Murphy -
Date of lrtspection:7117196
FLOW CONDITIONS
RESIDENTIAL: -
Design flow`930 gallons -
..Slumber of bedrooms:__3
Number of.current residents: 1. _
Garbage grinder Eyes or.no): No -
Laundry connected to system(yes or no): Yes -
Seasonal use(yes or no): No _.
Water meter readings,if available: nla _
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL: -
Type of establishment: n1a
Design flow:u _gallons/day
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: n1a
Last date of occupancy: n1a
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: ll gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components, date installed(if known)and source information:
1989
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
%
; ,
-
r�rY
� ��'3�4 •y« s ., �-... � ,i ,ru - s a �.��.z �' 't, t,y1"r�'����.�i k� ,a;�3t � �� 'u �lx Y s,
7
f'_f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 RoseMary Lane,Centerville
.Owner: Murphy.
Date of Inspection:7117196
SEPTIC TANK: X
(locate on site plan) - --
Depth below grade: 1'
Material of construction:X concreate_metal_FRP_other(explain) - -
Dimensions: L8'6-1-15'7-W4'10" -
Sludge depth:u _
Distance from top of sludge to bottom of outlet tee or baffle: 27'
Scum thickness:2'
Distance from top of scum to top of outlet tee or baffle:5'
Distance form bottom of scum to bottom of outlet tee or baffle: 16• _
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.)
Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: nla
Material of construction:X concrete_metal_FRP_other(explain)
Dimensions: nla
Scum thickness:n/a
Distance from top of scum to top of outlet tee or baffle:roa
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
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.)
n1a
revised 11115/95
( )
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
a. PART C - -- - - -
SYSTEM INFORMATION(continued) - ---
Property Address: 9 RoseMaryLane,Centerville
Owner: -Murphy
Date of Inspection:7117196
TIGHT OR HOLDING TANK:
(locate on site plan)_
Depth below grade: nla
Material of construction:X concrete_metal_FRP_other(explain) - -
Dimensions: rda -
Capacity: n1a gallons -
Design flow: n1a gallons/day
Alarm level: rya
Comments:
(condition of inlet tee, condition of alarm and float switches; etc.)
nla
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
n1a
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
nla
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM = I
i
PART C
SYSTE_KINFORMATION (continued) --- _
Property Address: 9 RoseMary Lane,Centerville
Owner: Murphy
Date of Inspection:7117196 - -
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain: -
Na
Type: _
leaching pits, number 1,00o Gallon leach pit. "
leaching chambers, number:nla
leaching galleries, number: nfa
leaching trenches,number, length: Na '
leaching fields, number, dimensions:Na
overflow cesspool, number:nfa
Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
The leach pit was empty at the time of the inspection.It is structurally sound.
CESSPOOLS:
(locate on site plan)
Number and configuration: "!a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: Na
Depth of scum layer: nfa
Dimensions of cesspool: . nla
Materials of construction: nfa
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
Na
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Na
PRIVY:
(locate on site plan)
Materials of construction: nfa Dimensions: nfa
Depth of solids: Na
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Na
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - -
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 RoseMary Lane,Centerville -
Owner:. Murphy -
Date of Inspection:7117198
SKETCH OF SEWAGE DISPOSAL SYSTEM: — -
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' - -- - _
3
D �
6 �
,4A
AB 17 �
Ac 3�
�c o�
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS MAPS AND CHARTS
(revised 1 V15195)
9
/ TOWN U?'BARNSTABLE
LOCATION (� l�/ � �CsI�ig+dz`/ �i✓ SEWAGE #7 7•--? <!) //
VILLAGE �I[ �t4 � ASSESSOR'S MAP & LOT/-/7 �
INSTALLER'S NAME & PHONE NO %G2 c�/ C. a,-ST
SEPTIC TANK CAPACITY /6 04
LEACHING FACILITY:(type) Cc�•9c�i �i T (size) (/) 61, X 4
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE
BUILDER OR OWNER Z/,V 1i9 r✓
DATE PERMIT ISSUED: / �►'
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No fi'�
' _ --_
� '
9
�f /�
��
��
� � �
.,� ASSESSORS MAP NO:
No:..._ _ PARCEL NO: Fxs'...�� ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.............----OF.......CP. ��-/-.(7.( - 'L"-----•---------..........----------
Appliration for Uhipvoal Works Tomitrurtintt thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
r )
-•••••-••.......... 5�=.►'►'J.!'tl .�C... r i✓t-. -------------- -------------- -----Lc� _--.----------------.--------._.........--.-.-----.--.....
Location.Address or Lot No.
.... �� 1:. .1?....... .................................... .................. ..... .. ..
Owner Address
Installer Address �'
d Type of Building Size Lot... feet
�. Dwelling—No. of Bedrooms.......... ..............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons.................._--------- Showers ( ) — Cafeteria ( )
Q'' Other fixtures ..................................
W Design Flow.......5 ............................gallons per person per day. Total da;l flow____.__--�-_�--4?.......................gallons.
WSeptic Tank—Liquid capacityl4QQ...gallons Length..?-���-.... Width..`.,77...__ Diameter................ De th._Lf.-.e F
x Disposal Trench—No..................... Width.................... Total Length._ ..____.._..._ Total leaching area_____.____ 1?`._..sq. ft.
I
Seepage Pit No----0_!gC----- Diameter__/_b__�EFF. Depth below inletZ?.. ._F .. Total leaching area-�!.!,_ ...sq. ft
Other Distribution box ( ) Dosi tank �-
~' Percolation Test Results Performed by. �:.�l.l'__ __ .�..... ............................ Date___........................................
,aa ' Test Pit No. 1 4Z..._._minutes per inch Depth of Test Pit._td_`.�....... Depth to ground water/.1p1?&
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------------- . --• ----------•---•--•-•--•-•...--.........................................................
0 Description of Soil ...... ... cl..........!.._....1_..-.I.................... -----------
U ----------------- -•----------------•--•------....------------•-----•--••-....-----_.--•--
---- --------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------_..
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 TITiE
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in ,
operation until a Certificate of'Com is % a n issued by the board of health.
Si /ed------....��. 7 ..� _. ................ j`� ........
C Days
Application Approved BY e -•------•---------------------------- ---------------•-•-•---•------- I f A..........
i��i�'�^V A)ate
Application Disapproved for the follows reasons---- ------------------------•-----•-------------•----------•-••-----------------------------------•---------•--
••------------•-------•-•------------•---------------------------•--••-•-----•-----•-------••----------------------••---•-------•--------•-............................................................
Date
PermitNo......................................................... Issued--•-•- .........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/: t/-tt .....................OF.....4 - c a. d�-L '' .........................
App iratiou for Disposal Works Tonstrurtiou rprutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
n 5 .. . .�2..y..... .► ............................ �- -t_�:...
.... .........._......_......._........_.._...._.
Location-Address or Lot No.
................................... .-----•-------•----.._......._......----------
Owner Address
................. .............................................................. •-----•--•----•••------•---•--.--•-•--••-••--•-•-.................---•--•------------------•---•-
Installer Address ¢,
Q Type of Building Size Lot__��t__�._�_�I.__—__Sq. feet
a Dwelling—No. of Bedrooms.........j______________________________Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
QIOther fixtures .................._...................................................................................................................................
W Design Flow___..6'5_�.............................gallons per person per day. Total daily flow........;�, _�__-....................gallons.
WSeptic Tank—Liquid'capacit}�_Qf?!1....gallons Length.0.14____ Width_�i-A.. . Diameter________________ D�LLe,p�t,,h,,_.�,,�___e`F
x Disposal Trench—No_ ____________________ Width.................... Total Length. _ Total leaching areA40—'"f=---.sq. ft.
Seepage Pit No.__Q6�----- Diameter_11 _4EFF__ Depth below inlet'eEF___ Total leaching area5#1!_1_...sq. ft. CO
Z Other Distribution box ( ) D s tank ( �-- 2' /Z-
Percolation Test Results Performed b A__FA:1A_iew.k_.._R E________________________ Date._________._____._.._______.___ _..._.. _
Test Pit No. 1.4P_Z..__.____minutes er inch Depth of Test Pit_/ _______.___ Depth to ground water_ �- vvAeo' /J
� P P P g'r /�--- --- -----
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----=----------------- -------------•---•------------•-----._....-•-------•------•-------....---•-•-•----....__........__.......---------------•-__-•--
D Description of Soil-- 7-3.6....IIIQ -- _lf _C)1�.._�_. ���� t ��_.. l fi7✓Yy1 0_ 31 7 '/
W
UNature 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 Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certifi cate Com issued by the board of health.
"followt
*Sied.....t....I '? _____------•--•-•-----------•------ S/�y
Application Approved By---•- --•---•------ ........................................ •••--• ......
:---
ate
Application Disapproved for reasons-----------------------------•---------------------------------------------------------------------•----------•-
.............................................. .................................................•------•---•-•--------•---•----••--------------•-•-----------------------------------------•--•-•-
Date
PermitNo......................................................... Issued-........................................................
.1
Date
f} THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... rn...........0F..........El . ..........................................
Tntifirtttr of TompliFaatrr
THjS IS TO: CERTIFY, That thq Individual Sewage Disposal System constructed ( ) or Repaired ( )
by2n>--
In taller r
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as dgsclibe in the
application for Disposal Works Construction Permit No----- _?_�_ u�................ da.ted_...-__.7-.. ______44__.__! ___,_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... '.. ^- Inspector....
( �� �--7 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
u 11 ..............OF....... /
No...Q_.. FEE........................
Disposal orko (Ions ' n rrmit
Permission is hereby granted.............
- ----�-...-.............................................................
to Construct ( ) or Repair ) an Individua Sewage Dis osal System
atNo..._' -T .................. ............... ..............•-=-..... ` ........................................................................
Street q
as shown on the application for Disposal Work Construction . ermit N .._•'_._`� _____: D ted_____'g'____. _�. .......
-•-�Y--•- --------- --•- ...............................
-------------------------- Board of Health
----
DATE.....• �--V4-------------•----�-----•-••-----
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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PROPOSED FLOOR LAYOUT
GENERAL NOTES:
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construction,they sl
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Specifications appe
discrepancies in wri
allowed to alter Drat
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2. Upon written receipt
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3. If code discrepancie
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4. All work performed s
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all other authorities I
list of applicable coc
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DEN B. All contractors, subcontr
responsible for the conte
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performance.
9 C. All manufactured articles,
CO installed, erected, used, (
accordance with manufa
D. All alternates are at the o�
Builder's request, constru
typical construction,as it
E. ARCHITECTURE by SPB I
Builder&Homeowner to
GARAGE
EXISTING FLOOR LAYOUT
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DATE 10-12-16
DRAWN BY SPI3
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r" DRAWING NUMBER
PRrlpne�n CCT r� r� i r-1 /1 . i •