HomeMy WebLinkAbout0048 SEABURY LANE - Health 48 SEABURY LANE, CENTERVILLE -
A=208-079
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No. 42101/3 ORA
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LOCATION —2$1y SEWAGE # q;` 162
VILLAGE ASSES1S_OR'S MAP & LOT 6$ 'G^I
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) a C �> (size) F,"X .,p
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well 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�achin acility) Feet
Furnished by
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
l� Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments
48 Seabury Lane 4
Property Address
Adelheid Werber iu1
Owner Owner's Name
information is required for every Centerville ✓ MA 02632 09/18/2018 '
�t e
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 o'..
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms
on the computer,
use only the tab Nicholas Geneseo
key to move your Name of Inspector
cursor-do not Wind River Environmental
use the return Company Name
key.
46 Lizotte Drive
r� Company Address
Marlborough MA 01752
City/Town State Zip Code
renew (973)830-6126 SI 13988
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true,accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
f'
09/18/2018
In pecto6 .ign' ure -- -� Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP.The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that<time.This inspectioi does not address how the system will perform
in the future under the same or different�ions of use.
t5insp.doc•rev.7/26/2018 rde S Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Seabury Lane
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is working properly at this time. Risers on the tank and distribution box with H2O
chambers under the driveway.
2) 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c Commonwealth of Massachusetts
i Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Seabury Lane
v
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
,o Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Seabury Lane
V
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
+� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 48 Seabury Lane
v
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
+ i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
48 Seabury Lane
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Seabury Lane
V
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 GPD
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 152 GPD
Detail:
Usage: 111,000 gallons/2 years =55,500 GPY/365 days = 152 GPD. See attached report.
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
The usage at 48 Seabury Lane, Centerville for the last two years:
January-June 2018 12,000gal
July—December 2017 19,OOOgal 1 `, , C C'
January—June 2017 14,OOOgal
July—December 2016 38,OOOgal
January-June 2016 28,OOOgal = J5� "moo
Best Regards,
Beth Flick,
Centerville-OSteCville-Marstons Mills Water Department
(Pli) 508-.428-.6691 (FX) 508.428.3508
bflick a,commfiredistrict.com
www.commwater.com
u VitAT1ER: 1
Commonwealth of Massachusetts
�n ;p Title 5 Official Inspection Form
1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Seabury Lane
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Wind River Environmental -See attached record.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? The quantity was measured by the pump truck.
Reason for pumping: To check the structural integrity of the septic tank.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Work Order# 0 217 067217 Cust# 1472151 Customer Since: 2 011 Tax: 6 .2 5 0 0 0
Job Comments Tech Comments
09/18/2018 CALL when on the way. 720-312-0569 Title V Cover(s) secured. Sept. 6th 8:15am 2018-351-2745.
Inspection for 9/7/18 will have consent form onsite - will 2/10/16 - Serviced 1500 gallons. Moderate solids/sludge.
have water records - as built plans sd. Levels OK. Recommend CCLS. (CB)kf
System Owner System Location
Adelheid Werber Primary Home
23 Sunset Lane 48 Seabury Lane
Osterville, MA 02655 Centerville, MA 02632
(508) 428-8890 ADELHEID WEBER (508) 428-8890
Service Date: TUE 09/18/2018 08:oo AM Frequency: Call to Confirm:
Service Type: Standard Previous Service: 08/31/2018
Approx. Gals: 1500 CCLS: Location Details:
Depth Below Grade:0 Custom Clean .. this is lsoo gallons;!
Cust Home: YES Filter. :.
Township: Ins fi ` 0.
County Barnstable BuildUp
6Q scri ti x 1 ,//
Inspection Title 5 (no incli{dn ^u rn }' 1 Q $ 36560000 $ 365 OQ '
P g 9 € �r
Inspection (Labor/Expaa,,ure gyp, e )per hr Y 1 0, $ 184 a9990 $ 1$5 00. ,
Inspection Title 5 BOH Fees 1 as $ 255eaa00 $ 25 00
Fuel / Energy Recovery—,. $„ _ 5 ,6i12::::$„ ,, 75...6 ....
Pumping 1001 - 1500 1.00 $ 364 6329 $ 364.63
2
^E }5
71-
e
icyr 3
.; M/
✓�..i w4am �`
Subtotal.: -$- " 1016.24
iz
gl,
We suggest these 3 keys steps to keep your system healthy:
" ° - • Regular servicing
Tax $ 0.00
• Use CCLS bacteria additive
Total $ 1016.24 . Use a filter
Disposal Site: Disposal Volume: Payment Detail:
Waste Code : 0.0000
Visa xxxxxxxxxx6062 09/2023
Sales Rep : CSR : Sherice Davis Due on Receipt
Truck : Technician : Nicholas Geneseo On Site : 08:18 AM P 0 Number:
Tech Notes :
System Operating Fine. Normal water level. Moderate top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear. No filter is present on the
tank; current tank can be outfitted with a filter. Recommended Installing a Customer not on site
filter. Cover(s) secured. Title 5 is a pass. Tank is at operating level with
tees intact, d-box is water tight and level with 1 outlet taking flow. Chambers X
are showing no signs of hydraulic failure at this time, recommend installing
filter on the outlet and pump annauly. NG. Customer Signature
ENVIRONMENTAL
a
Remit payment to 46 Lizotte Dr Suite 1000,Marlborough,MA 01752
c Commonwealth of Massachusetts
�1 Title 5 Official Inspection Form
'= w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Seabury Lane
v
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/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:
1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Plumbing and main line have good pitch. The area is well vented. There are no leaks.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
�y Title 5 Official Inspection Form
1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c � 48 Seabury Lane
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
There are risers on both the inlet and the outlet.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'x 5'x 5'
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
4"
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
15"
Tape Measure
How were dimensions determined? Ta p
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank is in good structural condition with the tees intact and the liquid level is normal. There are
risers on both the inlet and the outlet to 3"below grade. Recommend pumping annually.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Seabury Lane
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Seabury Lane
V
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
11
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The distribution box is 18"x 18"with one outlet taking flow.The box is watertight and level with a riser
to 1' below grade.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�n p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Seabury Lane
V�
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Seabury Lane
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
3 H2O chambers are in the driveway and show no signs of hydraulic failure at this time. There is no
staining on the walls and no breakout.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
'T Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Seabury Lane
v
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 Seabury Lane
v Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
vej .
. a 0
M1914/
for
3
t5insp.doc•rev.7t2612018 Title 5 Official t>spection Form;Subsurface Sewage:Dfsposal Systiem Page 46 of 18
TOWN OF BARNSTABIE
LOCATION Y SEWAGE tf
VILLAGE
ey-'ASSESSOR'S MAp& LOT
INS TALLER'S;NAME>&PMo' NO.
.. ...... . . .
SEPTIC TANK.CAPACITY �F
-77
LEACLi P!G FACILITY: (type)" (size)v9 �
NO OF BEDROOMS,
BUILDER OR OWNER `S
PERMLTDATE _ �`T� COMPLIANCE -DATE:
Separation Distance Between the:
Mazunlurr Adjusted:Groundwater<Tabte and Bottom vf'Ukhin&Yacibty Feet
Private Water Supply Well and Leachin
8 t
Facile
Y (Lf'any"wells,oust __
on„seta-or.-within 200 feet of leaclurig faciLty,)_ Feet:
Edge of Wetland and`Leaching>Facility(If any wetlands ersE
within 300 feet,of pc n cibty) j r Feet
Fumished.b
c:S
c Commonwealth of Massachusetts
�. ,p Title 5 Official Inspection Form
r
Ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Seabury Lane
v�
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 7+
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:
Used hand auger to dig hole to T with no damp soil.The system was installed in 1997 but there are
no records on file for ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
e
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Seabury Lane
L�
Property Address
Adelheid Werber
Owner Owner's Name
information is required for every Centerville MA 02632 09/18/2018
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.cloc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
D � ® � 9
9, 61 oo
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes p
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Misspaaf *psstem Cougtructiou Permit
Application for a Permit to Construct( )RepaipM upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address
or Loot No. 48 S e a b ur y Lane Owner's Name,Address and Tel.No.
Assessors n ' Map/Pa j e ,Mass . 0 2 63 2 t'r�v..�2 5 JF /.� /Q�S' rC�
Installer's Name,Address,and Tel.No.508-775-3338 Designer's Name,Address and Tel.No.5 0 8—7 7 5—3 3 3 8
Joseph P.Macomber Jr.
J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632
Type of Building:
Dwelling XX No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder(NO)
Other Type of Building RES No.of Persons 2 Showers 0 1.) Cafeteria(0 )
Other Fixtures Sink bowl tub 1 -Kitchen sink
Design Flow 220 gallons per day. Calculated daily flow 2 x 1 1 0 gallons.
Plan Date 4/3/9 7 Number of sheets Revision Date
Title
Size of Septic Tank 1 500 Type of S.A.S. 3-333OH2O Rechargers
Description of Soil M P d i l i m sand to fine -,a n d
Nature of Repairs or Alterations(Answer when applicable)0111 it t i n g cesspools . Installing 1 -1 5 0 0
gallon septic tank, 1 —Distribution box and three H2O 3330 Rechargers
Packed in 3 . 5 ' of stone .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this oo d of ealth.
401
Signed O" Date 4/3/9 7
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
Fee 1 a O.00
� iN�.� Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS
r Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
ZIpplication for Migpogal *p5tem Con5tructiou Permit
Application for a Permit to Construct( )Repairy(X�Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.. /a 8 Seabury Lane Owner's Name,Address and Tel.No. 4
Centerville,Mass. 02632 014 .4 5 s Ta 4e--'
Assessor's Map/Parcel:
`9
Installer's Name,Address,and Tel.No.508-775-3338 Joseph '.Macomber Jr.
'Designer's Name,Address and Tel.No. 0 8-7 7 —3 3 3 8
J.P.Macomber & Son Inc. Box 66- Centerville,Mass. 02632
Type of Building: ,
Dwelling XX No.of Bedrooms 2 Lot Size sq.ft. /Garbage Grinder(NO)
Other Type of Building RES No.of Persons 2 Showers(1 1) Cafeteria(0 )
Other Fixtures Sink bowl tub 1-Kitchen sink
Design Flow 220 gallons per day. Calculated daily flow 2x110 gallons.
Plan Date 4/3/97 Number of sheets Revision Date
Title
Size of Septic Tank 1 500 Type of S.A.S. 3-333OH2O Rechargers
Description of Soil Medium sand to fine sand
ram„
Nature of Repairs or Alterations(Answer when applicable)Omi tting ees Spools. Installing 1-1 500
gallon septic tank, l-Distribution box and three H2O 3330 Rechargers
Facked in ' of stone.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this old of Health.
Signed !." A Date 4/3/9 7
Application Approved by . ra Date
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( )UpgradeQxx)�
Abandoned( )by_J.P.Macomber & Son Inc.
E at 48 Seabury Lane Centerville.Mass. has lwon constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
1 Installer J.P.Macomber & Son Inc. Designer Josepfh jP.ffAc6mber Jr.
The issuance of this permit shall not be construed as a guarantee that the system will fit iorULdesigned.
{ Date Inspector
—————— ——————————————————————————=———
t r
No. !. Fee$ 5 0.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mi5po5ar bpgtem (Cougtruction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade.°TX�Abandon( )
j System located at 48 Seabury Lane 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. j
Provided:Construc ion Est be ompleted within three years of the date of 's permit. Pj
Date: ) r ` Approved by /`T 1
.V
y �
f '
CERTWICA'11ON Or SKETCII AND APPLICATION FOR A DISPC._
WORKS CONSTRUCTION PEItn,11'I' (WI'I'11OU'I' DESIGNED PLANSI
1 Joseph P.Maeomber___Jr.._: ;' c artily that tll(: application-for disposal works
construction permit signed by my _4/3/97 — , concerning the
pr:.)perty located at 48 Seabu]Zy Lane Gept erm; l l e Mai 2 meets all of the
following criteria:
• There are no wetlands within 300 feel of the proposed septic syste111
• There are no private wells within 150 l�ct of the proposed septic system
• The observed groundwater table .s rcct or greater below tlic bottom of the leaching facility
• There is no increase in flow and/or change in use proposed _
There are no variances requested or needed.
rr
SIGNED : �s DATE: �/3/97
LICE SEPTIC SYS'fEiV1 INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed s)stem. Also if the licensed installer posesses.a certified plot plan,
this plan should be submittedl.
f
.F
+�J
s t
� ��o
G
TOWN OF BARNSTABLE
C�
LOCATION ` —2—Y41Y SEWAGE # c1 l
VILLAGE ASSESSSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
_ v
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 7/ (size) Pt97��
NO.OF BEDROOMS L
BUILDER OR OWNER 1/ID/'1'lI�S14J"�%dl�
PERMTTDATE: 57 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site,or'within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within`300 feet of I achin cility) Feet
Furnished byCZZ
Wt