HomeMy WebLinkAbout0059 SETH PARKER ROAD - Health 59 Seth Parker Road
Centerville P
A = 169 198
No. 4210 1/3 ORA
Pendaflex
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TOWN OF B/A��RNSTABLE
LOCATION 59 St-=-r-}{ FA21C� F.V SEWAGE# Z.OZI OSZ
VILLAGE CskJrr�V 1 C,LG ASSESSOR'S MAP&PARCEL 00 "' 118
INSTALLER'S NAME&PHONE NO. K47�s�,"r 6• LSo$
SEPTIC TANK CAPACITY I C00 — A A<-
LEACHING FACILITY: (type) SOD 4tal. CAkPglh size) %7-5 Y Z5 4
NO.OF BEDROOMS 3 `'
OWNER !^ b-tj ?-D eZW( A ,s
PERMIT DATE: Z�Z I Z I COMPLIANCE DATE: Z I O Z
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 C g-e- W
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XA
1 -4 (9 Z
Z $ gp
3 spa s-t
4
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57
No. 1D)`- Fee NO
.-
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s
ftpliLAtion for Disposal *pstrm Construction 3permIt
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System tdividual Components
Location Address or Lot No. S g S C-T k P X 2 k iE V_ Owner's Name,Address,and Tel.No.
c� S(<, 0r -C�
Assessor's Map/Parcel 1 -7 o
Installer's Name,Address,and Tel.No.5_0844 ? 8 8 ?7 Designer's Name,Address,and Tel.No.
Rc�be� 3. Ovvt_ C.��✓tc,- �l03 t.�.L►,�'t�-s P'°"� C C2,4+2� 5�S �a�� ��� o i
Type of Building:
Dwelling No.of Bedrooms Lot Size ((o 156o sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 (D gpd Design flow provided L{ Z • Z-,r gpd
Plan Date 0 - Z s Zca Number of sheets Z Revision Date
Title 6Q Co E;-#Tn P�(L
Size of Septic Tank t oocn, Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 15 Xs i J f-11-7 L 0�0 ;z- r l
1N e/.s
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar of Healt
Signed.- Date S'"'7--q-2 �
Application Approved by Date '_-2-2
Application Disapproved by Date
for the following reasons
Permit No. ���' (7 3�� Date Issued ? -,G .1
Fee {VU ' 31
,
• THE COMMONWEALTH�OF• 01 Entered in computer:MASSACHUSETTS ���
PUBLIC HEALTH. DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes.
0(pplication,for Mispo4aY Opstent Construction j3ermit
Application for a Permit to Construct( ) Repair( ) Upgrade,(Y._Abandon( ) ❑Complete System Individual Components ,
Location Address or Lot No. pA F A 1Z 7 Owner's Name Address and Tel.No.
Assessor's Map/Parcel Q!I C( 8` {/� !�i"•J -
Installer's Name,Address,and Tel.No.SQ` y g �� Designer's Name,Address,and Tel.No.
Type of Building: tt
Dwelling No.of Bedrooms Lot Size t(o,Sbo sq.ft. Garbage Grinder( )
e
p Other Type of Building No.of Persons Showers( ),Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 C7 gpd Design flow provided 3 �( Z -�f gpd
Plan Date ' Z S J-L7 Number of sheets , Revision Date
Title �JC( �aE t, V.4&weaL...
Size of Septic Tank C.)C Type of S.A.S. d
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 64-r I Q4P (1.4. 1-:; ✓�+-r
aA)e.0 14.-•lo T)i�-
��a� � t4 1 l_�'-c4�-� °L ( (..��i4�•--v
Date last inspected: 210 M
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board:of Health.—
Signed . '`�~ Date '
Application Approved by q,,�l`� R C Date D_2 f! - '2 C42,/
Application Disapproved by Date
for the following reasons
Permit No. U t U> Date Issued 7 -2 G -P
THE COMMONWEALTH OF MASSACHUSETTS
.r•. BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded VQ
Abandoned( )by
af` r j AgA J?o has been constructed in accordance w
with.the provisions of Title 5 and the for Disposal System Construction Permit No. d? 1 -0" dated
Installer ?J6JeA-_, • Our (-0. ;.,,.e Designer Ale q,,•J � ���ti. < C�•�+.ti,,
#bedrooms Approved design flow �3 W gpd
G
The issuance of this pe it shall not be construed as a guarantee that the system will function)as designed.
Date u�7 Inspector ,�/ �.
------------
No. Q 5dZ- Fee /!1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction Vertnit
Permission is hereby granted to Construct( ) Repair( ) Upgrade(j) Abandon( )
System located at l'/ �.<tl1W,4,L + GG fi +''... Ll
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
.Title 5 and the following.local provisions or special conditions.
Provided:Construction must be c/ompleted within three years of the date of this permit.
Date 2�� (Z Approved by r
f ud.
Town of Barnstable
Regulatory Services
Richard V.Scali,Interim Director
BAWIMBI E
MASS. Public Health Division
039.
°rec na+' Thomas McKean,Director
200 Main Street,Hyannis,MA 62601
Office: 508-862-4644 Fax: 50&790-6304
Installer&.Designer Certification Form
Date: Sewage Permit# ZOZI 05 - Assessor's Map\Parcel
f y c�5
c _:Ye(kA � G Er)gineeriAS =mac Installer: &W(A ou)( pCe: xoc,
Address: ZSS Address: 3b 3
!�a5l ►,UQre.!%&.Y1 �y b1�c3 So AlYoe'r1 uvk111
On_Z Zte l 21 was issued a permit to install a
(date) (installer) _
septic system. at 5� fA� Pc�rl'�zt �`` based on a design drawn by
(address)
dated ► `Jfiu5t 95, Z�
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory..
I certify that the septic system referenced above was. installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed i iance with the terms
of the I\A approval letters (if applicable) orva�PLtH OF�,�SSgyG
c
JOHN L s�
CHURCHILL JR N
(tn taller's ' nat ) CML
.41
4
/1i P�
FF
Ce;h��inr .
F04y,n,ze_.t ( s SignaturVARNSTABLE
(Affix De t p Here)
PL �SERETRN TO PUBLIC HEALTH D SION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL .BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev$-14-13.doc
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
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.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key3
to move your David D. Coughanowr �^
cursor-do not Name of Inspector
use the return - p
key. Eco-Tech Environmental
Company Name
Q 43 Triangle Circle
Company Address ; r563w
(A
Sandwich MA City/Town State r-1
508 364-0694 Pending
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
I November 7, 2006
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.
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure
criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected.
No estimate or guarantee of system longevity is made or implied by a passing determination.
t5-2498.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
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:
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
t5-2498.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7, 2006
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 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.
t5-2498.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
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.
t5-2498.doc•08/06 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
59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
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-
1 0,000g pd.
❑ ® 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.
t5-2498.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
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?
SAS also
inspected ® ❑ 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)]
t5-2498.doc•08/06 Title 5 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
M 59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): n1a Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a-no plan
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 258 gpd
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: October, 2006
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):
t5-2498.doc•08/06 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
�^M 59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Owner's agent
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Age: 19+years. Certificate of Compliance issued 3112187(Board of Health permit#86-855)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-2498.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1.5feet
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.):
Sewer appears structurally sound with no evidence of backup or leakage into dwelling
Septic Tank (locate on site plan):
Depth below grade: 0.5feet
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:
8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth:
8 in
Distance from top of sludge to bottom of outlet tee or baffle 26 in
Scum thickness 0 in
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined?
Probe to top of tank
t5-2498.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, Go Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
every page. City/Town 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.):
Pumping not required at this time but maintenance pumping is recommended every two years. Tank
and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was
observed.
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):.
t5-2498.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
_ I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7, 2006
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 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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert At outlet invert
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 appears structurally sound with no evidence of leakage in or out. Some solids in sump.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-2498.doc•08/06 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
,M 59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
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:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No
standing effluent was observed to a depth of 2 feet below the top of the leach pit.
t5-2498.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
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.):
t5-2498.doc-08/06 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
59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is Centerville MA 02632 November 7 2006
required for ,
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.
LEACH LOCATIONS
PIT
A B
3 1 25.5 FE 5 FE
o-eox 2 29.5 Ft 6 Ft
2 3 33 FL 12 Ft
°n SEPTIC 4 39 f t 20 f t
o TANK
e I
EXISTING A
DWELLING
# 59
W
_Z
J
d'
W
H
3
SETH P /� RKER ROAD NOT TO SCALE
t5-2498.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
r
Commonwealth of Massachusetts
W Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Seth Parker Road
Property Address
Elroy E. Anderson, Trustee, EEA Realty Trust, c/o Carol A Felicetta
Owner Owner's Name
information is required for Centerville MA 02632 November 7 2006
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water: 20feet
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:
GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is 20 feet above groundwater
table.
t5-2498.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
COMMONWEALTH OF MASSACHUSETTS RECEIViED
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
m F DEPARTMENT OF ENVIRONMENTAL PROTECTION SEP 2 3 2003
d TOWN OF BARNSTABLE
HEALTH DEPT.
h
MAP
M 5�a PARCEL,
TITLE 5 LOT
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632 Cl
Owner's Name: VIRGINIA HAVLIN
Owner's Address: 59 SETH PARKER CENTERVILLE,MA 02632 n
Pate of Inspection: 9/3/03
Cap
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
{
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address and that the information reported below i
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:
X Passes
_ Conditionally asses
_ Needs Furth Evaluation by the Local Approving Authority
Fails
�nspector's Signature: Date: 9/3/03
�r
he system inspector shall submit opy of this inspection report to the Approving Authority(Board of Health or DEP)within
0 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
ent 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.
f
****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.
I
Titles 5 Inenantinn Fnrm 6/1 50000
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
roperty Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Pate of Inspection: 9/3/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
�C 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: i
YSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG T E
YSTEM'S USEFUL LIFE.
System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The syste D,
pon completion of the replacement or repair,as approved by the Board of Health,will pass.
nswer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits
ubstantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
ith 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.
D explain: n/a
/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
ipe(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
_ distribution box is leveled or replaced
D explain: n/a
n/a 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
D explain: n/a
I
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Date of Inspection: 9/3/03
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.
E
I. 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 co ly
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: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Date of Inspection: 9/3/03
D. System Failure Criteria applicable to all systems:
You must 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 ''/z 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 SYSTEM PUMPED TWO YEARS AGO BY OWNER.
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 suppl �.
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 M ith
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 0
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 b'
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 thn at
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.
I
i
4
f
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Date of Inspection: 9/3/03
Check if the following have been done. You must indicate "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 out in the previous two weeks
X _ Has the system received normal flows in the previous 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,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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenar ce
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 the 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)]
S
G I
k
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION f
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Date of Inspection: 9/3/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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))�
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,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: SYSTEM PUMPED TWO YEARS AGO BY OWNER
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:
1987 BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Date of Inspection: 9/3/03
BUILDING SEWER(locate on site plan)
Depth below grade: 14"
Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC
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: 8"
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: L 8' 6" H 5' 7" W 4' 10""
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 0"
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: 18"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate
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 relate
to outlet invert,evidence of leakage,etc.):
n/a
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN f
Date of Inspection: 9/3/03
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 ir to
or out of box,etc.):
D-BOX IS 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.):
n/a
R
Page 9 of 11
l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Date of Inspection: 9/3/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 4' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
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.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS O
FAILURE.PIT HAD P OF LIQUID IN 1T AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS
NEVFe2 HAD MORE THAN P OF LIQUID IN IT.BOTTOM IS AT 5 FT. PIT HAS APPROXIMATLEY 3'
(!!* SAC4 �.
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
e
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Date of Inspection: 9/3/03
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.
Lv
O.A Sun
u
� �o
Page 11 of 11
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 SETH PARKER CENTERVILLE,MA 02632
Owner: VIRGINIA HAVLIN
Date of Inspection: 9/3/03
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+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- 12+FT.
i
;21 f
I�- TOWN OF BAR
Loc �G? �, a T SEWAGE #
,-VILLAGE F'��✓� M `
ASSESSOR'S MAP LOT 0
co INSTALLER'S NAME PHONE NO-1 fJ-Z,1,0T L,y `% O
SEPTIC TANK CAPACITY ?�
LEACHING FACILITY:(type),- (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �
DATE PERMIT ISSUED: "
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ,✓
�. ' t �
33 /
i
4�
TOWN OF S4WOWiGH
LOCATION: qqCeft r q
VILLAGE: 11f'
LOT k /-/0 - /q 1� PERMIT#: Sv SSA
INSTALLER'S NAME:
INSTALLER'S PHONE P
LEACHING FACILITY: (type) Rlt (size)
NO.OF BEDROOMS: I J,,
OWNER:: elf-e y 4glojefw)
PERMIT DATE:
COMPLIANCE DATE:
` DRAW DIAGRAM ON BACK
LEACH
LOCATIONS ,.
1 25.5 FE 5 FE
3
0 o-sox 2 29.5 FE 8 Ft
2 3 33 FE 12 FE
jarSEPTIC
.] TANK 4 39 FE 20 FE
EXISTING A
DWELLING
# 59
W
Z
J
K
W
H
a �
3
SETH PARKER ROAD NOT TO SCALE
Fxs. _Z)...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEAL-TFL
.......OF.......................................................................................
R ApplirFation for DiuVuiial Works Tomol.rurtion Vanti#
App ication is hereby made for a Permit to Construct Repair ( ) an Individual Sewage Disposal
j Syst11 gat
........................._.... ,�� ---------------- .............- .?.�/..--------.. ..........................................
L on-Address Oro o.
................................... ..........................................
W #rAddress
r-a
------------------------------------------
. ................................ ........
Installer Address
Type of Building Size Lot.... f__ .Sq. feet
U Dwelling—No. of Bedrooms........... .........................Expansion Attic ( !*-e3 Garbage Grinder ( `i-
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures----------------------------------------------------------------------------------------------------------------------------------------•-•••......--
W Design Flow....... .....................gallons per person per day. Total daily flow............v...............gallons.
fY4 Septic Tank—Liquid capacityl.�'� allons Length................ Width................ Diameter.-.............. Depth....---.....---.
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No(p_r_-t---- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.............------. Depth to ground water---------------------.-.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--------..-_--_..----...
-------------•--------.--------•---•--------------•.----------------------------------•-•-•---•----•-----------------------------
0 Description of Soil------ r..G ---------------------------•----••-•---------------- -----------•----------------------------------------------------------------
x
U --------------------------------------•-••-••----•-------------•---•-••----------•------------------••-----------------------------•----••-....----------------•-------------------------------•-------
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
........--•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TT T;..i: y g g p y
� of the State Sanitary Code— The undersigned further agrees not to place the system in
operation unti� ti•sate of Co m liance has beeni.4uSd by the boar,oVof health.
d -•-•-- .11..... .
Dates-o
Application Approved By............................
= =- .... {
Date
Application Disapproved for the following reasons-------------•-------------------•-----------•--------•----------------------------------------------------.-----
-----------------------------------••--------------...---•--------------------•---------........--------•---...---------•--------------------------....................................................
Date
Permit No..... Issued_.......................................................
Date
r�
:;. Af �...
THE COMMONWEALTH OF MASSACHUSETTS
d BOARD OF HE.AfLT
R' F
....... ...................OF......................................... .....................................
Applirtttion for 14spnsttl Works Tumitrurtinn rrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at.,�
(sir � ,e y ,p �t^� �~
d•'r ..... ...... ..:.. ....p '"'5.^ 5 .._. F..................... ". ... ...
i, g ; Fla LoeaTion Addr s *°"` o?,Lot No
b ]5^!+ :_ .............................................
1 or Address
a .. .`_!--!---4"::. _I ._.y!.....�a,,..-:__ ........................................ ..... .... ,n
Installer Address
U Type of Building Size Lot._ F, . ?..Sq. feet
Dwelling—No. of Bedrooms................. ..........................Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
aqOther fixtures ------------------------------------•--••--------------••••-••-•--.
W
Design Flow...... :. ...............•.•_._.gallons per person per day. Total daily flow._._...... ..r-'_....__._._.....gallons.
WSeptic Tank—Liquid capacity "'.gallons Length................ Width................ Diameter................ Depth...............
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit %---------. Diameter.................... Depth below inlet.................... Total leaching area.................. it.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
.
L�. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
....------•...................•------•----•----•-•---•---•----------•-------.........._...-••.......................................... ....
..--------------
0 Description of Soil.................................................................................................................................................--......................
x
W
--------------------------------------------------------------------------------•---------------------------------------------------------------------------------..................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
------------------•-•-••-----••--•--•_.--•-•--------•-•-•-•----•-•-•-----••-•-•-••-•-•••••-••-••---...._•--•---••---
Agreement:The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of T ITL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operration, until Certi"-cate of Compliance has beeenissued by the b ardof health.
Igl ........... ..._........_
"a- C+ D e
Application Approved BY C s .l,�r�......-•.................. ......
Date
Application Disapproved for the following reasons-----------------------•--------•-------•--------•------------••-----------------•--------------------...----••--
••••---••••--•-•---••--••----••--•-----••••---•••----•---•-•--•----••---•-•---••--•-......---•••........_._.........-•-•-•••...••--•----•----•••---•-------•••••-•••••....-•-----•----•---•••-•-....-•---
_ Date
Permit No.....7fE�• ` Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
;,"----BOARD OF HEALTH
r
QLrifirttr ,af (�utttfittnr�e
THIS IS TO CEREIFY�That the Irid,,;XiduaI Sewage Disposal System constructed ( ) or Repaired ( }
td
by.......... 1---•-•.. . ...........
•. -- .
-^ Installer s
at-------- -----••--••- --- --•---- ------
has been Installed in accordance with the provisions of T i T' j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No��._.�� `��� da.ted._._______________________.__.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............. .................................... Inspector......... ==<'_-,.--- --•-----------.---------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................oF..........• --� "d '.fl ~ ................... `�`` " d�a
NIS�ro. ................. FEE �.'- 5.........
Displastt1 Works Tnstruatt anti#
Permission is hereby granted...... - ....................... -:
to Constructf( Lp-L Re air ( h an Individual Sewage:Dls osal System p��. 1I/..!//1
at No............1..�.'L�:-a ............................. ��. c'_.1. �✓______.......���S..__... .1.'.�.�.�EX�......
-• .
street
as shown on the application for Disposal Works.Construction Permit N'o• Dated.__-_
Board of Health
DATE/. ----------------------------------
r
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
. i
f '
5 t tJE�t.E, F-,1u�1 V(-'S BED��t5
f
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USE IOC>D &A.LLONS nc 'la►aK - I
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ek'v i�mt,t3.2 sF C z.s: 30 G910
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To rA c. U 1A1
p 11J }411.1.02L6$S �^" 2% I
WCHARD
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LIVA/ t
'� . 1�•G7�o ��^ SZ 5 ,,/ :h:a -'oP aF F�117
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�N� SET'iacK TiEl�t1��E 1�'4ENT5 z?F�t E �s ��► �-1� h� .
ro W►J �F�r`��STAF .>� A iJI� 1S ��`T` ��.1 a t�1T: /-�`�.�.....,�,I..� rr:���.,.��_.�:
/iTt-+im -r iF- -F; LDzmz?-PL.A,) .t. This RAC Is N���S�R �NHN IN57RuMFWT
n SuRYC
Y AND T HE: oFFSET'S •sHovyty 5H4)uL-D 1qoT
eST&13USH L.z�>"T L)NE5•
CEN TER VI LLE
Sr'"1 PARKER
CONTOUR
j 1 `RKER ROAD ® PROPOSED SPOT GRADE
—— 98 —— EXISTING CONTOUR
+ 96.52 EXISTING SPOT GRADE o
W— EXISTING WATER SERVICE m
fr 1 �4•
LOT 655 1 1 29 TEST PIT o2 0
1 1
AREA = 0.36 acres j 1 SCALE: 1"=20'
W U 1 1 v
Oel
uj
oc 1 s WE
1 1 59 SM PARKER RD
1 1 3
1 1 -
j i LOCUS MAP
o I I LOCUS INFORMATION
PLAN REF: 386/090
TITLE REF: 21 559/1 2 2
T.0.F, PARCEL ID: MAP 170 PAR. 198
Z @ EL. 53.0 PROPERTY IS IN ZONE II, IS IN ESTUARIES PROT.
FLOOD ZONE: PROPERTY NOT IN FLOOD ZONE
rn
D I SEPTIC SYSTEM
pa to REPAIR PLAN
rn I 51.4 LOCATED AT:
r 59 SETH PARKER ROAD
T15M = EL. 51 —z-1_I 51.4 = CENTERVILLE, MA
TOPOP OF BLUE5TESTONE ._
STEP O PREPARED FOR
+ CD
EXIST. 1000G � - 51 SCOTT M. BROWN
SEPTIC TANK AUGUST 25, 2020
50.2
EXIST. 1000G head 50.7 ����� OF sf9�
LEACHING PIT I o DARREN
ME
0.2 No. 0
TP-1 ��
� 50— _' TP-® 2 � _ 4NIT00p� �Z�
h
25' ' _ — MEYER & SONS, INC.
2soo• _ `23•— _ P.O. BOX 981
—50 EAST SANDWICH, MA. 02537
PH: (508)360-3311
FAX: (774)413-9468
meyerandsonstitle5@gmail.com
SHEET 1 OF 2 J 1894
ELEV. TOP 'NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS
FOUNDATION: BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE
(Existing) FINISHED GRADE (50.0)
= 53.0 F.G.EL: 51.60 F.G.EL• 51.45 F.G. EL: 50.10
4:�f MAINTAIN 2% MIN SLOPE OVER LEACHING AREA
" F.G.EL 50.72 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2"
• . ;; STONE OR FILTER FABRIC DOUBLE WASHED STONE
:A C" .• y ,
V A 4" SCH 40 PVC
10"I 6 MIN.) jWE3
31123 3E31
!' TEE'S ARE TO BE 14 INV. 47.$O ® S 1% ( � ®®®®®®®®®
4" SCH 40 PVC 2 EFF. DEPTH ®®®®®®®1®®
INV. 49.45
INV. 47.60 4' 1 2 X 8.5' 4'
EXISTING OUTLET BAFFLE PROPOSED DB-3
.. . . . DISTRIBUTION BOX EFFECTIVE LENGTH = 25'
INV. 49.70 (H20) INV. ELEV.= 47.00
EXIST. 1,000 GALLON SEPTIC TANK
GAS BAFFLE TO BE INSTALLED ON ����� OF Mgsf9� BREAKOUT
OUTLET TEE AS MANUFACTURED BY yo
NOTES:
TUF-TITE, ZABEL, OR EQUAL SP DA RYEEN M. TOP CONC. ELEV.= 48.00 ELEV.= 48.00
1) CONTRACTOR SHALL VERIFY ALL EXISTING N 4 INV. ELEV.= 47.00 ®E3
PIPE INVERTS PRIOR TO CONSTRUCTION ®®®
2) D-BOX SHALL BE SET LEVEL AND TRUE TO RE�j ®®I®®®®®
GRADE ON A MECHANICALLY COMPACTED SIX '�NITAR�a� NEW®®®®®a
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM EL.= 45.00
310 CMR 15.221(2) ��
3.75' 5 FT. 3.75'
3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK EFFECTIVE WIDTH = 12.5'
WITH 1500 GALLON SEPTIC TANK IF FAILED, SEPARATION 5.80 FT.
DAMAGED OR UNDERSIZED.4) NSTALLINLET & OUTLET TEES W/ SEPTIC SYSTEM PROFILE SOIL ABSORPTION SYSTEM �SECTIONI
GAS BAFFLE AS REQUIRED BOTTOM OF TESTHOLE EL: 39.20
(500 GALLON LEACH CHAMBER)
SOIL LOGS P#: TPT-20-145 GENERAL NOTES: DESIGN CRITERIA **IN ZONE 11 AND ESTUARIES PROT.**
DATE: JULY 21, 2020 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL NUMBER OF BEDROOMS: 3 BEDROOM DESIGN
SOIL EVALUATOR: DARREN MEYER, R.S., CSE 161
# 4 BOARD OF HEALTH AND THE DESIGN ENGINEER. SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF)
if 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
WITNESS' DAVE STANTON, BARNSTABLE HEALTH DEPT. OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN
LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: DAILY FLOW: 110 G.P.D. X 3 BR = 330 G.P.D.
- 310 CMR 15.405 (1) (8): �
Elev. TP-1 Depth Elev. Tp-2 Depth t FROM mcMRts.221(7 -Li`ACHING' U ` y( GARBAGE GRINDER: NO (not designed for garbage grinder)
50.20 0" 50.25 0" TO BE 4.00 Ff PROVIDED) SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK
A LOAMY SAND A LOAMY SAND 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFIL.LED PRIOR LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F.
IOYR 4/1 1OYR 4/1 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
49.70 6" 49.67 7" 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
B B USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4'
LOAMY SAND LOAMY SAND FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN , , , ,
1OYR 6 6 10YR 6 6 ENGINEER BEFORE CONSTRUCTION CONTINUES. STONE ON ENDS & 3.75 STONE ON SIDES: 25 L x 12.5 W x 2 D
� 5. A ASSUMED ON �+,�MED DATUM.
47.70 30"
47.58 32„ 6 THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF BOTTOM AREA: 25 x 12.5 = 312.5 SF
C C THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF.
0 EL 45.70
PF TEST HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF
f"�
if MEDIUM MEDIUM 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ.D
SAND SAND S.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
2.5Y 6/4 2.5Y 6/6 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
39.20 132" 39.25 132" 10. EXINSTIINNG LEACHING M BE PUMPED, CRUSHED AND FILLED PER TITLE 5. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
PERC RATE <2 MIN/IN. (•C2- HORIZON) 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 59 SETH PARKER ROAD, CENTERVILLE, MA
NO GROUNDWATER OBSERVED 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY Prepared for: Scott M. Brown
• I. Damn M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. Design and Site Plan by: SCALE DRAWN DATE
to conduct $oft evaluations and that the above analysis has been performed by me consistent with the 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. MEYER&SONS,/NC. N.T.S. DMM 08/25/20
requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October. 1999. 15. ALL PIPING TO 8 UN E 4" SCH • 1 8' Fi LESS SPECIFIED BOX98f 40 / ( PO
REV DATE CHECKED SHEET N0.
EAST SANDWICH,MA02537
5M-W22922 DMM 2 of 2