HomeMy WebLinkAbout0130 SACHEM DRIVE - Health 130 Sachem Drive
Centerville P
A = 229 106
46 f 0 JatSCYCL&oCoyl
UPC 12534 a
NASTINGS. UN
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TOWN OF BARNSTABLE
LOCATION SEWAGE # 0�/
VILL AGE koe'r Zr,l^i/�°/ /�_ ASSESSOR'S MAP & LOT Ibb
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C
INSTALLER'S NAME&PHONE NO.� .,Po csl�; _S'l/a l c
SEPTIC TANK CAPACITY z'_!ro ®
LEACHING FACILITY: (type) L e4g-1-1 R_J2- (size) 490
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: I '*lam COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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4 3 ijL-133 --
TOWN OF BARNSTABLE,
LOCA'i w 13Q ca c&,, Dr SEWAGE #
V>Z LAGfi C��► er y Jdle ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1 O0A'a
L£ACfIlNGTACKJTY: (type)
NO.OFBEDROOMS _.._ -
BUILDER OR OWNER
PERMrrDATE: 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 fnw-ility) Feet
Edge of Wetland and Leaching Facility(If any et lands exist
within 300 feet leaching facility) / ACC/ e Feet
Furnished byt -E/ �' G
t+
at
13-76{
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i
No. / '`7' /'� Yee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Z(pprication for �Diopaar *p.5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) omplete System ❑Individual Components
Location Address or Lot No. �.�� �V.�l.,D{ Owne ' Name,Address and Tel.No.
Assessor's Map/Pazcel
Installer's Name,Address,and Tel.No. a Designer's Name,Address and Tel.No.
(q\
`6 k O
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures f �-1 c
Design Flow ILA(A�/ gallons per day. Calculated daily flow `� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank i Type of S.A.S. ✓�
Description of Soil ` co At�_�'l
Nature of Repairs or Alterations(Answer when applic ble) �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance,with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu this adY
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued ''
No. do-It *14.1110"
A _ kFee
THE COMMONWEALTH OF MASSACHUSETTS __;, Enteredb computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
f
0[pprication for XDie;po!5ar *pgtem (fon.5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System El Individual Components
Location Address or Lot No. t+ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel y����� � �
Installer's Name,AddresKanqTeh.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size: sq.ft. Garbage Grinder( )
Other Type of Building No. of,Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow �A gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ..- ( Type of S.A.S. w
v , 11Z 'v
Description of Soil
v
Nature of Repairs or Alterations(Answer when applicable) (`� _ 12
w w ` P
Date last inspected: c"
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Sighed— Date_- / L
Application Approved by ' Date
LQ3
Application Disapproved for th fo owing Masons'
Permit No. .f s;: Date Issued �f.»
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(tertif icate of QCompriance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( � )Repaired ( )Upgraded(` �.
N
Abandoned( )by .. V
M fwJ��
at has been constructed in accordance
with the provisions of Title 5 and a for Disposal ystem onstruction Permit . dated
Installer Designer ow
The issuance of this er/mit shall not be construed as a guarantee that the sy `m ill function as d gned.
Date I Inspector e' i� /Irfi 'i
---------------------------------------
No. Feet
Y THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
liopogal *potem (Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this I.
Date: (� F Approved b .
l
1 1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, ✓ S, hereby certify that the application for disposal works
k
construction permit signed by me dated 19 ��-(� , concerning the
property located at ti--,'O Q--e_ CC-C meets all of the
following criteria:
'This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
••//The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
u There are no wetlands within 100 feet of the proposed septic system
41 There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
6� T re are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
Z
plicable]
the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) J �
B) G.W.Elevation +the MAX.High G.W.Adjustment
DIFFERENCE BETWEEN A and B ;
SIGNED : DATE:
[Please Sketc ro plan of system on ack].
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
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.
A. General Information I
1. Inspector. �...�f Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
Cityrrown State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the.proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
0-/ --
1-3-12
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to.the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•t 1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste •Page 1.�' J of 17
T
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
%-AuuSiirfaGe Jcwaye Disposal System Fvrrii -Not for VGiiirStary ASSessments
M 130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure`criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
13) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. if"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) ,System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static.water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health): . , -
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y J❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y . .❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
t
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if .
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a g p y ry s ents
130 Sachem Dr
Property Address
P Y
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. City[Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ . The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
❑ ® due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
`I{ ❑ ®' Any portion of the SAS, cesspool-or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
- tributary to a surface water supply.
❑ . ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
El ® 'Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool"or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
..of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection.
Area-IWPA) or a mapped Zone 11 of a public water supply well
If you,have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
System in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts °
W Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�nM 130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ElWere as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site'inspected for signs'of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) 310 CMR 15.302 5
PP P ) I O]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x-#of bedrooms): 440
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
5
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 10-2011
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.).
Grease trap.present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-t 1/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M
130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (f known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
18"
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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 12
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: .
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth: 12
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G M 130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 20
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
15" �
How were dimensions determined? Tape
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 is in good condition with baffles installed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: ,Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
" Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessriments
°M 130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):,
Depth of liquid level above outlet invert 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.):
Good condition with water at working level and no sign of back-up from trench.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. Cityrrown . State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ teaching chambers = number:
❑ leaching galleries number:
® leaching trenches number, length: 1-80'x2'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach trench in good condition with no sign of back-up into d-box or surrounding stone.
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
t5ins-11/10 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9'w 130 Sachem Dr
M
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 130 Sachem Dr
M
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. Cityfrown State Zip Code Date of Inspection .
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
'D t
6 o 36
� ' � - yx'6 9-D- ffo°
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Original design plans on file show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM ' 130 Sachem Dr
Property Address
Barnett Bornstein
Owner Owner's Name
information is required for every Centerville MA 02632 1-3-12
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
r
TOWN OF B4,NSTABLE
LOCATION cL� Dr - SEWAGE #
L LACE C eat I4 U, `�e ASSESSOR'S MAP�c L®T
INSTALI ER'S NAME&PHONE NO.
(SEPnC TANK CAPA►CrrY
f LEACH NG FA.CILrrY: (tM) ±/ e r g C (size) X
1�
N®.0F'BEDR00MS_ Y__r__
)BUILDER CAR OWNER.
j PERMIT®Aa'%E:.._.. ,._.. - —- COMPUA►NCE DATE:
Sepamdon Distwice Between the;
Maximum Adjusted Groundwater Fable to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (I£any wells exist
on,sate oe dn/'Hein 200 feet of leaching facility)
Edge of Wedand and Leaching Facility(If any wetlan(l5 exist
within 300 feet ff. caching facility)
Funi,ished by �w✓� _ ! .
4
i
a
Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.
A. General Information \ ��
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (316 CMR 15.000).The system:
®, Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1-26-10
Inspector's Signaturdf Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the .
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to.the buyer;if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
� 1
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Dispo I System-Pa 1 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 62632 1-26-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
-❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass.inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that.the system is not functioning in a manner which will protect public health,
safety and the:environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soiVabsorption.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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis; performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ , ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
' necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the'interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CM 15.302(5)]
t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required], ❑ Yes ® No
' Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 10-09
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General information
Pumping Recorrds:.
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
` Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑. Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract '
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5lnsp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 18
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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 12"
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1500gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle 20"
Scum thickness 1
Distance...from top of scum:to top.of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information cont.
Y (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness '
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in worldng order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
Good condition with water at working level.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1-2'x80'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach trench in good condition with no sign of back-up into d-box or surrounding stone.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 130 Sachem Dr
Property Address
Bank Owned (Contact'David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for Centerville MA 02632 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
D
B
0 0 .
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Sachem Dr
< Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Centerville MA 02632 1-26-10
every page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Original designplans show no groundwater at 12'.
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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PARCEL , 1 O
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner's Name: MR.ROBEDEE
Owner's Address: 83 WHITMAR RD.COTUIT,MA 02635r
m
Date of Inspection: 3/15/04 2
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
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Telephone Number: 508-564-6813 FAX 508-564-7270 rr*t .
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of itle 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Fu e Evaluation by the Local Approving Authority
_ Fails
Inspector's Signature: Date: 3/15/04
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The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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.
' Titla 5 Incnactinn Fnrm C%11 5/?00f) 1
Page 2 of 11
9
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
i
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
'i
X 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:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes: I
I
_ One or more system components as described in the:"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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.
i
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
i
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a j
n/a The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The s stem will ass
Y 9 P P� g �Y Y P
inspection if(with approval of the Board of Health):
I
_broken pipe(s)are replaced-
-obstruction is removed
I
ND explain: n/a
I
Page 3 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a.septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
D. System Failure Criteria applicable to all systems:
You trust indicate"yes"or"no"to each of the following for alLinspections:
Yes No
_ X Backup of sewage into facility or system component due to 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 %2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of 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 1 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. [This system passes if the well water analysis,performed at a DEP
certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
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)
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
A
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
Check if the following have been done.You must indic' to "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 Were any of the system components pumped)ut in the previous two weeks
X _ Has the system received normal flows in the revious two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection'?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out'
X _ Were all system components,excluding the SAS, located on site'?
X _ Were the septic tank manholes uncovered,ojened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,de;I th of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if diff rent 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:
Yes no
X _ Existing information. For example,a plan at he Board of Health.
X _ 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(3)(b)]
5
•Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 1
Does residence have a garbage grinder(yes or no):NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): nia-- b (j�
Sump pump(yes or no): NO 7
Last date of occupancy: n/a 0
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
20 YEARS,NEW 3 YEARS PER OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
F
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• Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions:H 10' 6" H 5' 7" W 5' 8"-"
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 19"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7 I
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
TIGHT or HOLDING TANK: (tank must be pumped 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: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Wa
R I
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: 0
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
1 leaching trenches, number, length: 80
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
SOIL WAS PROBED,TRENCH IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM
SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 4'6".
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
Q
Page 10 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet.Locate where public water supply enters the building.
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trench �o
in I
Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 SACHEM DRIVE CENTERVILLE,MA 02632
Owner: MR.ROBEDEE
Date of Inspection: 3/15/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT.
Town of Barnstable Health Inspector
SINE r Office Hours
a Regulatory Services 8:30-9:30
Thomas F.Geiler,Director 3:30—4:30
r r
BMWffrABM
MASS.
Public Health Division
iOrFv �e Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE
Date: 2/12/09
1. General Information: Size of Property: .48 acres
Address: 130 SACHEM DRIVE CENTERVILLE MA 02632 Map 229 Parcel 106
Name: CAVIC,MICHAEL G&HELEN C Phone#: 508-957-2265
2a. How many bedrooms exist at your property now?3
2b. Are you planning to add any bedrooms? YES If yes,how many? 1
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?4
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. S ow all egating
CD
rooms in the home and the proposed amnesty apartment. Provide width measurements of any op n door ays. :�
Please label each room clearly.
C7 CV
3. Is the dwelling connected to public sewer? NO
T�.
If the dwelling is connected to public sewer;skip questions#4 through#9 below.. ;'
00 x~
4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone Cn
C� r-
r, r ri
5 . Location of dwelling is INSIDE or OUTSIDE. a Zone of Contribution to public sup y wells?
6. Is the dwelling connected to an PUBLIC WATER
7. Is a disposal works construction permit on file? YE or NO
8. If yes,how many bedrooms were approved according to this permit? Bedrooms.
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
-------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY 2 00—�('7 7
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: Date:
Q;/nealth/wpf les/amnestyapp
,e w .•
y Town of Barnstable p
l Health Inspector
oFt Tqk, Office Hours
1% Regulatory Services 8:30—9:30
Thomas F.Geiler,Director 3:30—4:30
* &UMSTABLE.
9� MASS.
Public Health Division
.erFo�,tA Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE
Date: 2/12/09
1 ni-e Vr 0 C4-
1. General Information: Size of Property: .48 acres N.'4o ke.d % ` �
Address: 130 SACHEM DRIVE CENTERVILLE MA 02632 Map 229 Parcel 106
Name: CAVIC,MICHAEL.G&HELEN C Phone#: 508-957-2265
2a. How many bedrooms exist at your property now?3
2b. Are you planning to add any bedrooms? YES If yes,how many? 1
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?4
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing
rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways.
Please label each room clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. :Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone?
5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?
6. Is the dwelling connected to an PUBLIC WATER
7. Is a disposal works construction permit on file? YES or NO
8. If yes,how many bedrooms were approved according to this permit? Bedrooms.
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
-------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: Date:
Q;/health/wpfiles/amnestyapp
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No. �0 1_00_3 Fee $50.00 /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS
ZippYication for Mi0pozat *pgtem Con.5truction Permit
Application for a Permit to Construct( )Repair J(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.R i chard Ro be de e Owner's Name,Address and Tel.Nos 0 8—7 7 5—3 7 4 2
130 Sechem Drive �, �„ ,�1 Richard Rob edee
Assessor's ap/Parcel _ G ` U-,N " Centerville,Mass. 02632
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.Nos 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son inc. J.P.Macomber & Son Inc.
'Box 66 Centerville,Mass. 02632 Rox 66 Centerville,Mass. 02632
Type of Building:
DwellingXXXNo.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations Answer when applicable)Re 1 a c i n house 1 i ne. line from
P ( PP ) p a
the house to the septic tank. Shouls have been replaced when the
new system was installed.
Date last inspected:'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental ode and not to place the system in operation until a Certifi-
cate of Compliance has been issu by this o of alth. '
Signed Date 1 /2/0 3
Application Approved by � kW Date :3 d-
Application Disapproved for the following reasons
Permit No. 2,Lv —D0 3 Date Issued 1 &J
J
No. �00 3 Fee $S 0•.0 0
t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: tomlYes
rt- PUBLIC HEALTH..DIVISION--TOWN OF BARNSTABLE., MASSACHUSETTS
'M Rpprtcatton for Mtsspogar *pztem Conotructton Fermat
Application for a Permit to Construct( )Repair RX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.R i chard Robe de a Owner's Name,Address and Tel.No5 0 8—7 7 5—3 7 4 2
130 Sachem Drive �I Richard Robedee
Assessor's Map/Parcel . , b 4^,J t •
y- /oL Centerville,Mass.0 2 6 3 2
Installer's Name,Address,and Tel.No. 5 0 8-7 7 5—3 3 3 8 t Designer's Name,Address and Tel.Nos 0 8—7 7 5—3 3 3 8
J.P.Macomber & .Son inc. J.P.Macomber & Son Inc.
Box 66 Centerville Mass.02632 lox 66
Centerville,Mass.02632
Type of Building:
DwellingXXXNo.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No:of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
E Plan Date Number of sheets T Revision Date
Title
Size of Septic Tank Type of S.A.S. .-
Description of Soil
i
Nature of Repairs or Alterations(Answer when applicable)Replaeinq houseline. line from
the house to the septic tank. Shouls have been replaced when the
new system was installed.
Date last inspected:
Agreement:
The undersigned°agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu=bythiso of alth.
Signed r Date 1 /2/0 3
Application Approved by _ Date:ad 3
Application Disapproved for the following reasons
Permit No. Date Issued
- -------------------- -- - — —
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired'(XX)Upgraded( )
Abandoned( * )by J.P.Macomber & Son Inc.
at 130 Sachem Drive Centerville,Mass. has been constructed j accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. .?00,r—UU3 dated 1/3 3
Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc.
The issuance of this permit shall not be construed as a guarantee that the system will function�as�designed.
Date f)1101 10 Z Inspector 1 F' fin/ L N V,�,
---------------------------------------
No. .2 dv 3 QO 3 Fee $5 0.00
i
THE COMMONWEALTH OF1 ASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mtopozar *p2lem Conotructton Vermtt
Permission is hereby granted to Construct( )Repair.6VIDlpgrade( )Abandon( )
System located at 130 Sachem Drive Centerville,mass.
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions'or special conditions.
Provided:Construction must be completed within three years of the date of this-permit
Date: 6 I'2 3l0 7i Approved by �/`, ��_
� F
TOWN OF BARNSTABLE
.��jn J �//���� lm,
LOCATION you-bbl�L �� SEWAGE #
I
VILLAGE Of"e t Zh,. r "V ASSESSOR'S MAP & LOT
0
INSTALLER'S NAME &PHONE NO. �I r� cl
SEPTIC TANK CAPACITY ,/ S U O
LEACHING FACILITY: (type). eel J oe (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE`. 7— COMPLIANCE DATE: D
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within.200 feet of leaching facility) Feet-
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
I
Furnished by
11136 ~�
-7j
4 21Lr32
A 3 -6 2 °`"
'77
Lf0,C A T 10N Lof1`7 S E W A G E PERMIT N0.
(tSf•, t�t� ShF� �2iy�
VILLAGE
INS--TA LLER'S NAME & ADDRESS
/9*,p
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED / /7�
L�,6
5AC,14A- J ��✓�
No.. ......... ..........f...................
THE COMMONWEALTH OF-MASSACHUSETTS
BOARD OF HE:A TH
......... ---------------OF... . ..............
Appliration -for Ditipwial Works Tomitrurtion Prrmit
Application is hereby'made for a Permit to Construct or Repair ( 1,4000'an Individual Sewage Disposal
System at:$
....... .................................................................................................
tion�. d ss or Lot No.
...... .......LIZ, .. ..........57�----4 .................................. ...Address..........................................
caner
.... ......... _/...n/ .. .. ......A.:---&.... ...................................................................................................
Installer Address
ype of Building Size Lot............................Sq. feet
U
Dwelling]KNo. of Bedrooms.:.........................................Expansion Attic Garbage Grinder
a4 Other—Type of Building ............................ No. of persons..__-___._________-_________ Showers Cafeteria
P-1 Other fixtures -------------------------------------------------- ------------------------------------------------------------------------------------------
�4 W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
r4 Septic Tank—Liquid capacity------------gallons Length________________ Width.-___-- ........ Diameter_....-._.._____ Depth.--.____._....
Disposal Trench—No_--------------------- Width._-_-___-__-_______- Total Length____-_-------___---_ Total leaching area-------_----------sq. f t.
Seepage Pit No_____________________ Diameter________-_________-_ Depth below inlet____...._........._. Total leaching area------------------sq. f t.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------------- ............................................................ Date----------------------------------------
Test Pit No. I------------_-minutesperinch Depth of Test Pit-------------------- Depth to ground water_------.___.___.. --
G14 Test Pit No. 2................minutes per inch Depth of Test Pit-.-_._.____________- Depth to ground water_-.-.__._.-.-_.__-__-_
) ------------------------ ------- ..........................................................................................................
�
0 Description of Soil.----S .... ......I.. ... . - --------------------------------------.------------------------ -------------------------------:---------------
U ................................................................................................... ----------------------- ---------- ---------
--------------------------------------------------------------------------------------------------- __' ___ --.= A--- __ - -
U Nature of Re Alterado ns r when appli le A)z177 ......yZe-wo,------
s 04_.ed,244&------- . ....... . . ... .
- ----- - ------�e�----- o
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ssued by the board o hn alth.
Sign .... .. .. ------------------------- ......... ---------------- ---
Date
Application Approved By......... .... I .... ........ ....7r-A' 77-------
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued... . ....................
Date
-——---—-----—-------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_. . ..... OF... ` X.--/�,?'(a
Appliratinn -fear Diipv.ial Works Tonstrurtion Vrrutft
Application is hereby`made for a Permit to Construct ( ) or Repair ( /,)-man Individual Sewage Disposal
System at: . n
i h t ,� It t t4x
._........' ..... ...............-•••.. .•••......_. .... or Lot No.
................._........•.. ••-•--..............................•...........................................................
f Location-Address
-/ r //r .i.
--------------------- --------•-•-••-------•------.:y_f....-----•......-----•............--••--••. ••--•••••••-------.......--•-•-•-••-••--••--•--•-----...------•--•--•-•------•••-•._.......•......
Owner �, .� Address
W _ r •... .f /.V
r Installer Address
UType of Building Size'Lot----------------•___-___-_--Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—Type of Building t
g ---------------•---•------._ \o. of per,ons------------....--•---___--- Showers ( ) — Cafeteria ( )
P4 Other fixtures -•-•-------------------•--------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity__--------gallons Length---------------- Width............._. Diameter__.-_...---._-__ Depth.-.._-----_---
x Disposal Trench—No-____________________ Width---_...____-__---_-- Total Length-------------------- Total leaching area-------------- .....sq. ft.
Seepage Pit No..................... Diameter•-_-__--_--_---__-- Depth below inlet__-_-_-_._----__--_ Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a
Percolation Test Results Performed by-------------------------------------------------------------------------- Date..-•--•---•----------------------------
Test Pit No. I................minutes per inch Depth of Test Pit__--_-__----..._--. Depth to ground water-----------------.------
�, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-.-.___-__-.----_----
o�i —/_.1-------------•--•---•-------•-•--•---.......................................__.......................
D Description of Soil._._ _.- -_ — ._lam
---------------------------=-------------------------------------------------------------------------------------------------------------------------
U -------------- ------------- -----------------------------------------------------------------------------/----------�------------------------------- ' (l
►�rl ----•-•------------------------------------------- -----••-•-•-----•-------- - .1 i. ---- --- / - •---/-j..
W - ------- --•----------------•�•-----......--- i ----- ---------•--•-----------•------ •--- •---,
Nature of Repairs or Alterations—Answer when applicable � 17"...V / ., �*, f� � � `7+�r _•__ �� x r. .u•
U P ---- ---- ------- -•- -----
---—t e.-------------7• j /f -- .� --- �i< A!'r r---- f -{(" fi w.- /• ,.
Agreement: v
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n ssued by the boaAd of al 1. '/
r Signed �J T � .
L
-- ---•-•-------•-
Application Approved B Date
Date
Application Disapproved for the following reasons--------------------------------------------------------------------------•---------------- --------------•----
•----------------------•----•...------------•-----------•-----------------------------------------------------••-•--•-----------••--••-•--------•-------•••--•-......---...-•----••--------------•-•----
Date
PermitNo......................................................... Issued...................-----................................
- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. OF......r`..... . ..... .
Trrtif irate of f 1,11m haurr
THIS IS `O CERTIFY;,That the Individual Sewage Disposal System constructed ( ) or Repaired
-, ._..
, Installeri. f
at----------- -----------` . d,.-iw•t='-•-------`-'---='•-` r�
--------•------- -•------- -----•----....•.-•----------------•--•-------••-•-•---•-••......----••-••----
bas been installed in accordance with the provisions of Ar"1l XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._. ���3 -- --------------------- dated..............y.�7....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-_--- .....-• -7-7..._..---•-----•-•--••--•-•----•-•..... Inspector.... . -1 ------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0J� /.2P/+'/ .........OF............./%1., E•. ._ fir........
No........... .......... FEE.....---
%sVviial Workq Tpnitrnrtinn Vrrntit
Permission is hereby granted_jrz!'_r_t_ � ....__.j.�----r/�✓t�III--<'l�_ ..........................." � ....................
to Construct ( ) or--Repair '( i)'�an Individual Sewage Disposal System/,
''�
at No r ,�� �.< r --. . --- f, - f
Street
as shown on the application for Disposal `Works Construction er' it Nd._. !?._.✓"2__._ Dated__.___7�-�� 7
� = f -- ---
�/_
DATE...----�--=--------------------•----------------------------------------- Board of Health/
FORM 1255 HOSES & WARREN. INC.. PUBLISHERS