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Home My WebLink About0375 SOUTH MAIN STREET - Health 375 SOUTH MAIN ST., CENTERVILLE A= 207 070 IIII AEcraEo lIII > UPC 12543 No.53LOR MASTfNf99�Q1N AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATIO SEWAGE # VILLAGE_ ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /r ! (size) NO.OF BEDROOMS XA BUILDER OR OWNER de- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility IS-1 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 f leachin aci ' ) Feet Furnished by /% I j7 — zx i Cr ,yo i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=207070&seq=1 10/1/2013 COMMONWEALTH OF MASSACHUSETTS I N EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS = ICj DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 µ ILLI.-1,yt F N ELD TR D`. CO.XI GoNcmor 410 ARGEO PAUL CELLUCCI DA\ID B. STRL HS Lt.Go�cmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �F 19 �o sv,or.c PART A 'r 4�3r�, 96) CERTIFICATION 1. Property Address: South Main -Street Centerville Address of Owner: � � ,,' , •�,. Date of Inspection:4 8 98 (If different) Name of Inspector:,? 7 I am a DE F appro a system tnspectorrpurs'Gahr to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son In ._ Mailing Address: Rox tiF C'PntPrtrillQ,p4ass . 92632 Telephone Number: CERTIFICATION STATEMENT I cerlify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function ano maintenance of on-site sewage disposal systems The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails ,�/ Inspector's Signature: 49 � Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 Cn1R 1 5 303 Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: 4110 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The s>ste.m, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate y��o, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratfon. or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tan: as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: hnp/twww.magnet state ma usvaep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR. •. PART A CERTIFICATION lcontinued) P,o-er', Aocress:South Main Street Centerville,Mass. °"^er . Jeff Komenda D,!r of tn�pcc ,on: 4/18/98 -! SYSTEM CONDITIONALLY PASSES (continued) dyl Sewage backup or breakout or high static wale( level observed to the dtstnbvtien DO= Is c-r DtPels) or due to a broken, sealed or uneven distribution box. The system will pass Board of Health) C)escribe observations: broken pipels) are replaced obstruciion is removed distribution box is levelled or replaced AZ6 The system required pumping more than four times a year due to broken or obstr.c.ed - :z -e s ,nspe Ct.on .I (with approval of the Board of Health) broken p,pe(s) are replaced obslrv,7110n is removeo C• FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /6i ronC.t,ons exist wh.ch require funher evaluation by the Board of Health in order to Bete!( e health• wfery and the environment 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERh1INES THAT THE SYSTEM IS NOT F 0',:'•'_ 'WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT ,F a Cesspool or prCVY is within 50 feel of a surface water �d Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt m.arsn :i SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPR'DFR'.-k7 THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND S-kFF"1 ,N E•NVIRON'MENT: The system has a septic Lank and soil absorption system (SAS) and the SAS is w tr,n r - tobutary to a suriace water supply. ,[�) The system has a septic tank and soil absorption system and the SAS is within a Zone 0' The system has a septic tank and soil absorption system and the SAS is within 50 tee'. Di 3 The system has a septic tank and soil absorption system and the SAS is less Ihan ',00 'ee'. _ Private wale( supply well, unless a well water analysis for col,form bacierla ane the well is free from pollution from that facility and the presence of ammonia n'trogen an7 less than 5 ppm method used to determine distance 'y'4 (approximation no: 3) OTHER u i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: South Main Street Centerville,Mass . Owner: Jeff Komenda Date of Inspection: 4/1 8/9 8 DJ SYSTEM FAILS: You ,I must indicate er;• er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 15.303. The ba>is for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged S.qS or cesspool. Static liquid level in the distri ution box above outlet inven due to an overloaded or clogged SAS or cesspool A'�/ 'lst Liquid depth in caup"l is less than 6" below invert or available volume is less than 1/1 day flor,. Required pumping more than 4,times in th last year NOT due to clogged or obstructed pipe(s) Number of times pumped �.AV1111d1'/ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water suppls Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 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 wish no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: /'�j� The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 100 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information (revised 04/25/97) Page 3 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Centerville Corners Motor Lodge Property AddressSOUth Main Street Centerville,Mass . O%.ner: Jeff Komenda Date of Inspection: 4/1 8/9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, Eluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of battles or tee:, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on The facility o.vner (and occupants, if cUfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptaole, 115.302(3)(b)J (r*vlrrrrd 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO\ FORM PART C SYSTEM INFORMATION Centerville Corners Motor Lodge Propeny Address: South Main Street Centerville,Mass . Owner Jeff Komenda Date of Inspection 4/1 8/98 FLOW CONDITIONS RESIDENTIAL: Design flo, A1.4 R p.d./bedroom for S.A.S 'umber of bedrooms i /� 'umber of current residents Caroage grinder (yes or no) —29 .auncn connected to system (yes or no) ,Vj Seasonal use (yes or no) N/Q /1 `',a!er meter readings. if available (last two (2) year usage (gpc!: 15ii0o jnCl�zz C Sump Pump ;yes or no): 41/� .as; case of occupant- A)d COM.MERCIAUIN'DUSTRIAL: )J /J T;pe of establ shment mo Co_- /loci!e, Design allons/day Crease trap present. (yes or no)_!l2f9 lncuwial waste r+olding Tank present. (yes or no) ip 'on sani;ar, waste discharged to the Title S system (yes or no) "'elU acer meter reaeings, if available .as: pate of occupancy.�L--/ OTHER: ;Descr,bei 1a5! tale O' Occupancy �y1 GENERAL INFORMATION PU.ti1PI.NG RECORDS and source of information System pumped as pan of inspection: (yes or no) B 7istt�GL CK�Iy If yes, volume pumped gal ns Reason for pumping �Z, P�� , TYPE OF Septic tank/distribution box/soil absorption systems Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) -C. I/A Technology etc. Copy of up to date contract? C"ner /-1W APPROXI,titATE AGE of all components, date installed (if knc)vm) and source of information: Sewage odors detected when arriving at the sue: (yes or no) t:•v:••d 01/15/5ll P•g• 5 o1 10 I 1 g q U Cl - r 1 q p� aco 3aticans Q� (v - I�Oj DO O 9 GI 16n'S 3qS' q q7 -- I SUBSURFACE SE`NAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE.%1 INFOR&ATION (continued) Centerville Corners Motor Lodge Property Address: South Main Street Centerville,mass . o ner: Jeff Komenda Date of inspection:2/18/98 BUILDING SEWER: 'ocate on sale plan. Depth below grade ,.�atenal of consuuc ion: Ii iron �0 PVC _ other (explain) Distance (r /Private water supply well or suction line /d 7" Diameter 'Y Com nits (condition of joints, venting, evidence of leakage, etc.l T )� 27 �— Jul > n SEPTIC TANK: �il/I//� � r ,7 AX;' ,oca:e on site plan; Dept,) celo- grade k✓I' C U�:J�r^S a;er'al o' cons!ruclion concrete _metal _F,berglass _Polyethylene _other(expla n) ,an'., is meta; list a � � gertiftcate Compli Is age confirmed b ance (Yes/No) iC��`��' .rJy �'' ,•a�,t--ltT�7'•�; .°� gyp' ,,•,(c>{, �;I'•.��;.� 5��''�c>�n.�;. D.,mens,ons Y 7r 1 t r: i ,9��fi�i91., � Ec�1�/;2'�Ci Slucge death Distance from top of sludge to bonom of outlet tee or banle. Sc,.m thickness 6_ D,stance from top of scum to top of outlet tee or baffle Q l Distance from bonom of scum to botto of outlet tee or banle. ric.+ dimensions were determined: /j Comments recommendat,on for pumping, condit of inlet and outlet tee or baffles]depth of liquid level in relation to outlet inverti, struciural. n,e ra\ evidence of leakage, etc.) i �G ! -> rGY7 ieTa ' 09 . GREASE TRAPA�e ,ovate on site plan Deptn oeloN grade �� •,�atenal of construelionitl/-�concretaVOmetal4/�Fibergl,iss4l/,VPolyethyleneVOother(explaln) .1X Dimensions. Scum thickness. Distance from top of scum to top of outlet tee or baffle:VA D,stance from bottom of scum to bottom of outlet tee or baffle: Also Date of last pumping: fiIV/ Comments: vecommendauon for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, strucl—ra nlegrity, evidence of leakage, etc.) rr.v:sod Pig• 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Centerville Corners Motor Lodge Propert ddress: Somth Main Street Centerville,Mass . Jeff Komenda Da!e a t"spect'on: 4/18/98 TICHT OR HOLDING TANK:&✓( lank must be pumped pnu: to. or at time, of nsaeoioni tlocj. e on s.:e plan) Dep:." oelo- grade construciionv,4concrete4-) metallU�/F�berglass�L!�Polyelhylenet other(exp a�n) d1A -- D,mens,onl Cesign 1 gallons Design � o•� 'i gallonslday Alarm .e. A1, Alarm in working order/f/jQ 1'esAZI, Nu Date o pie.sous pumping. COmmen:s tcone,t,cn of inlet tee, condition of alarm and float switches, etc ) DISTPiEjTiO.v BOXI V-1' <a.e :e plan) .✓e.:" : _. o level above outlet nven .r/D incite -t I=sel and distribution is equdl, evidence of soli s Carryover, qvidence of leakage into or out of bo_, e:: IL ti. _ -6V—te.",4P 13 AVO— kP9 7g-4,Ak 5x) f)A, JL -- s y At's jay ck� d �� :.vTi tee^Uti r y�, � � - -- PU."P CHAI-tBER:�'e IIOCJ:c cl s,te plan) P -a,'k,ng order (Yes or No)-,& order (Yes of No) Co,mmer:s note ;orc•i,on of pump Chamber, condition of pumps and Lapppuunnenninces, etc.) Q 7.g. 1 0f 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.v PART C SYSTEM INFORmATION (continued) Centerville Corners Motor Lodge Propene Address O-n8outh Main Street Centerville,Mass . Dateof InSptCliOn: D : 4/18/98 dle O L p ,/,��f� f � SOIL ABSORPTION SYSTEM (SAS):zP��(J + ^'J iocale on site plan, if possible: excavation not required, but Mai, be approx,mated by non•jn;tvsive rne:-ocs, if not determined to be present, explain: leaching pits, number leaching chambers, number: leaching galleries, number: leaching trenches, number,length. leaching fields, number, dimens,ons. o,erflow cesspool, numb Z>— Al;ernahve system. IJA Name of Technology: Commen:s ;, to C nc�i,on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, et . A: Ic CESSPOOLS: ,ioute on Site plan) Numper and configuration: (� Depth-top of liquid to Inlet invert y T Depth of solids layer:__ AA Depth of scum layer, ka D—ens,ons of cesspool._ AA ' v.ater,als of construction: 1 ino'cahon of groundwater Al ,nflo- icesspool must be pumped as pan of inspection) Comments :note conCition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: )/ 'cote on site plan) M.iterials of construclion: D:mens.o-, Dep,n of solids _ — Commen's note condit,on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, el- , D.9. a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SS � PART C Centerville CornerSYSMZ OI P!E&6.-�J ON (continued) Property iddress: Sout�i Main Street ---- �� Owner: Centerville,Mass. Date of Inspection: Jef f Komenda 4/28/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: j inc ude ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where publi Ovate/ wpply cne into house) I Gr J�-O- 0 y lrwu.c Cc/25/97) Page 9 of 10 I� ��s� _�� '�I � 1 / % �`. i T /� \ /� �,� . � �+ � ' U E.` � � t � j; / i �C n c, � �� ' I Yy . � � \ � :r`i ,� ��. I I �' ` i =� y �-- � w_ -- ( � N k �-�-- � �/ �-a �h , �/' � y,s / ` �� L� 99 � � � 0� ��i �� i.i 7 �� 3'- \ �w / � � �� i � � �, ;�� _� .y. � ri 4� � '�� :.�� I � i f • SUBSURFACE SEWAGE DISI SYSTE•vs INSPECTION FORtis SYSTEM INFO; Ov tcontlnued) Centerville Corners Motor Lodge Proper. ^�"eSSSouth Main Street Centerville,Mass . ° Jeff Komenda Date of insaect 4/28/98 1 Dean to CGounowater�p Feet Please :nc:ca,e al! the methods used to determine High Croundwa'C( Eli, 6 on. / OO:a;nec from Design Plans on record �Qose,.ai,on of Site (Abuning propersy,� bservauon hole, base menr s-ma etc ) k-"De.emine it from local conditions C ne" —:r) local Board of health p-mp,ng records ccal exca.ators. nstallers Sc -SCS Data Desc, oe - •c).)r own words how you established the High Grouncw-xer::evallon. Must be complete,'; Installed and repaired septic systems at this location. Water was not encountered at 16" Used Water contours map. Gahrety & Miller Model 12/16/94 (....r.-.r-I--n:.rr- e-r-.�-n mrr..r..r.,rr,:-.r.•.+vr*:-r.•-•en.--.-re-tiz:r.x�..-r.rr.. - ... .. _ -.. - as-c•r.-Rrr_�-.-r-T----T- 11'OHN OF Barnstable BOARD OF HEALTH S011SURFACF SEWAGE DISPOSAL SYSTEM IN311FCTION FORM - PART D - CF.RTIFICATIO'1 -T r.. •r+�-rs �ra-r-nrrrsrri+rr:rrn-rors�vr rsm r.•r-rrrrr<r m+rr�r•,-.-r^ r - -TYPE OR PRINT CI.EARLY- PIZOPERTY INSPECTED Centerville Corners Motor Lodge STREET ADDRESSgn„th Main RtrePt Centerville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # b2`01b OWNER ' s NAME Jeff Komenda PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sc1fi 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City Stat. t I P COMPANY TELEPHONE ( 508 775 - 3338 FAX (508 1 790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and complete as of the time ofeinspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : ��SystemsPASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with 'Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . W V Inspector Signatur Dated One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the I)OARD OF II EAL7'lI If the inspection FAILED , the owner or "operator shall upgrade the eyetem within one year oC the date of the inspection , unless allowed or required otherwise as provided in 310 CHR 15 . 305 . partd . doc C ' r w s s THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Dircctor of the ion ut Water Potlution Control 375 SOUTH MAIN ST., CENTERVILLE A= 207 070 IIII AEcraEo lIII > UPC 12543 No.53LOR MASTfNf99�Q1N AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATIO SEWAGE # VILLAGE_ ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /r ! (size) NO.OF BEDROOMS XA BUILDER OR OWNER de- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility IS-1 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 f leachin aci ' ) Feet Furnished by /% I j7 — zx i Cr ,yo i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=207070&seq=1 10/1/2013 COMMONWEALTH OF MASSACHUSETTS I N EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS = ICj DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 µ ILLI.-1,yt F N ELD TR D`. CO.XI GoNcmor 410 ARGEO PAUL CELLUCCI DA\ID B. STRL HS Lt.Go�cmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �F 19 �o sv,or.c PART A 'r 4�3r�, 96) CERTIFICATION 1. Property Address: South Main -Street Centerville Address of Owner: � � ,,' , •�,. Date of Inspection:4 8 98 (If different) Name of Inspector:,? 7 I am a DE F appro a system tnspectorrpurs'Gahr to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son In ._ Mailing Address: Rox tiF C'PntPrtrillQ,p4ass . 92632 Telephone Number: CERTIFICATION STATEMENT I cerlify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function ano maintenance of on-site sewage disposal systems The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails ,�/ Inspector's Signature: 49 � Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 Cn1R 1 5 303 Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: 4110 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The s>ste.m, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate y��o, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratfon. or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tan: as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: hnp/twww.magnet state ma usvaep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR. •. PART A CERTIFICATION lcontinued) P,o-er', Aocress:South Main Street Centerville,Mass. °"^er . Jeff Komenda D,!r of tn�pcc ,on: 4/18/98 -! SYSTEM CONDITIONALLY PASSES (continued) dyl Sewage backup or breakout or high static wale( level observed to the dtstnbvtien DO= Is c-r DtPels) or due to a broken, sealed or uneven distribution box. The system will pass Board of Health) C)escribe observations: broken pipels) are replaced obstruciion is removed distribution box is levelled or replaced AZ6 The system required pumping more than four times a year due to broken or obstr.c.ed - :z -e s ,nspe Ct.on .I (with approval of the Board of Health) broken p,pe(s) are replaced obslrv,7110n is removeo C• FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /6i ronC.t,ons exist wh.ch require funher evaluation by the Board of Health in order to Bete!( e health• wfery and the environment 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERh1INES THAT THE SYSTEM IS NOT F 0',:'•'_ 'WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT ,F a Cesspool or prCVY is within 50 feel of a surface water �d Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt m.arsn :i SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPR'DFR'.-k7 THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND S-kFF"1 ,N E•NVIRON'MENT: The system has a septic Lank and soil absorption system (SAS) and the SAS is w tr,n r - tobutary to a suriace water supply. ,[�) The system has a septic tank and soil absorption system and the SAS is within a Zone 0' The system has a septic tank and soil absorption system and the SAS is within 50 tee'. Di 3 The system has a septic tank and soil absorption system and the SAS is less Ihan ',00 'ee'. _ Private wale( supply well, unless a well water analysis for col,form bacierla ane the well is free from pollution from that facility and the presence of ammonia n'trogen an7 less than 5 ppm method used to determine distance 'y'4 (approximation no: 3) OTHER u i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: South Main Street Centerville,Mass . Owner: Jeff Komenda Date of Inspection: 4/1 8/9 8 DJ SYSTEM FAILS: You ,I must indicate er;• er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 15.303. The ba>is for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged S.qS or cesspool. Static liquid level in the distri ution box above outlet inven due to an overloaded or clogged SAS or cesspool A'�/ 'lst Liquid depth in caup"l is less than 6" below invert or available volume is less than 1/1 day flor,. Required pumping more than 4,times in th last year NOT due to clogged or obstructed pipe(s) Number of times pumped �.AV1111d1'/ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water suppls Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 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 wish no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: /'�j� The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 100 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information (revised 04/25/97) Page 3 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Centerville Corners Motor Lodge Property AddressSOUth Main Street Centerville,Mass . O%.ner: Jeff Komenda Date of Inspection: 4/1 8/9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, Eluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of battles or tee:, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on The facility o.vner (and occupants, if cUfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptaole, 115.302(3)(b)J (r*vlrrrrd 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO\ FORM PART C SYSTEM INFORMATION Centerville Corners Motor Lodge Propeny Address: South Main Street Centerville,Mass . Owner Jeff Komenda Date of Inspection 4/1 8/98 FLOW CONDITIONS RESIDENTIAL: Design flo, A1.4 R p.d./bedroom for S.A.S 'umber of bedrooms i /� 'umber of current residents Caroage grinder (yes or no) —29 .auncn connected to system (yes or no) ,Vj Seasonal use (yes or no) N/Q /1 `',a!er meter readings. if available (last two (2) year usage (gpc!: 15ii0o jnCl�zz C Sump Pump ;yes or no): 41/� .as; case of occupant- A)d COM.MERCIAUIN'DUSTRIAL: )J /J T;pe of establ shment mo Co_- /loci!e, Design allons/day Crease trap present. (yes or no)_!l2f9 lncuwial waste r+olding Tank present. (yes or no) ip 'on sani;ar, waste discharged to the Title S system (yes or no) "'elU acer meter reaeings, if available .as: pate of occupancy.�L--/ OTHER: ;Descr,bei 1a5! tale O' Occupancy �y1 GENERAL INFORMATION PU.ti1PI.NG RECORDS and source of information System pumped as pan of inspection: (yes or no) B 7istt�GL CK�Iy If yes, volume pumped gal ns Reason for pumping �Z, P�� , TYPE OF Septic tank/distribution box/soil absorption systems Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) -C. I/A Technology etc. Copy of up to date contract? C"ner /-1W APPROXI,titATE AGE of all components, date installed (if knc)vm) and source of information: Sewage odors detected when arriving at the sue: (yes or no) t:•v:••d 01/15/5ll P•g• 5 o1 10 I 1 g q U Cl - r 1 q p� aco 3aticans Q� (v - I�Oj DO O 9 GI 16n'S 3qS' q q7 -- I SUBSURFACE SE`NAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE.%1 INFOR&ATION (continued) Centerville Corners Motor Lodge Property Address: South Main Street Centerville,mass . o ner: Jeff Komenda Date of inspection:2/18/98 BUILDING SEWER: 'ocate on sale plan. Depth below grade ,.�atenal of consuuc ion: Ii iron �0 PVC _ other (explain) Distance (r /Private water supply well or suction line /d 7" Diameter 'Y Com nits (condition of joints, venting, evidence of leakage, etc.l T )� 27 �— Jul > n SEPTIC TANK: �il/I//� � r ,7 AX;' ,oca:e on site plan; Dept,) celo- grade k✓I' C U�:J�r^S a;er'al o' cons!ruclion concrete _metal _F,berglass _Polyethylene _other(expla n) ,an'., is meta; list a � � gertiftcate Compli Is age confirmed b ance (Yes/No) iC��`��' .rJy �'' ,•a�,t--ltT�7'•�; .°� gyp' ,,•,(c>{, �;I'•.��;.� 5��''�c>�n.�;. D.,mens,ons Y 7r 1 t r: i ,9��fi�i91., � Ec�1�/;2'�Ci Slucge death Distance from top of sludge to bonom of outlet tee or banle. Sc,.m thickness 6_ D,stance from top of scum to top of outlet tee or baffle Q l Distance from bonom of scum to botto of outlet tee or banle. ric.+ dimensions were determined: /j Comments recommendat,on for pumping, condit of inlet and outlet tee or baffles]depth of liquid level in relation to outlet inverti, struciural. n,e ra\ evidence of leakage, etc.) i �G ! -> rGY7 ieTa ' 09 . GREASE TRAPA�e ,ovate on site plan Deptn oeloN grade �� •,�atenal of construelionitl/-�concretaVOmetal4/�Fibergl,iss4l/,VPolyethyleneVOother(explaln) .1X Dimensions. Scum thickness. Distance from top of scum to top of outlet tee or baffle:VA D,stance from bottom of scum to bottom of outlet tee or baffle: Also Date of last pumping: fiIV/ Comments: vecommendauon for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, strucl—ra nlegrity, evidence of leakage, etc.) rr.v:sod Pig• 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Centerville Corners Motor Lodge Propert ddress: Somth Main Street Centerville,Mass . Jeff Komenda Da!e a t"spect'on: 4/18/98 TICHT OR HOLDING TANK:&✓( lank must be pumped pnu: to. or at time, of nsaeoioni tlocj. e on s.:e plan) Dep:." oelo- grade construciionv,4concrete4-) metallU�/F�berglass�L!�Polyelhylenet other(exp a�n) d1A -- D,mens,onl Cesign 1 gallons Design � o•� 'i gallonslday Alarm .e. A1, Alarm in working order/f/jQ 1'esAZI, Nu Date o pie.sous pumping. COmmen:s tcone,t,cn of inlet tee, condition of alarm and float switches, etc ) DISTPiEjTiO.v BOXI V-1' <a.e :e plan) .✓e.:" : _. o level above outlet nven .r/D incite -t I=sel and distribution is equdl, evidence of soli s Carryover, qvidence of leakage into or out of bo_, e:: IL ti. _ -6V—te.",4P 13 AVO— kP9 7g-4,Ak 5x) f)A, JL -- s y At's jay ck� d �� :.vTi tee^Uti r y�, � � - -- PU."P CHAI-tBER:�'e IIOCJ:c cl s,te plan) P -a,'k,ng order (Yes or No)-,& order (Yes of No) Co,mmer:s note ;orc•i,on of pump Chamber, condition of pumps and Lapppuunnenninces, etc.) Q 7.g. 1 0f 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.v PART C SYSTEM INFORmATION (continued) Centerville Corners Motor Lodge Propene Address O-n8outh Main Street Centerville,Mass . Dateof InSptCliOn: D : 4/18/98 dle O L p ,/,��f� f � SOIL ABSORPTION SYSTEM (SAS):zP��(J + ^'J iocale on site plan, if possible: excavation not required, but Mai, be approx,mated by non•jn;tvsive rne:-ocs, if not determined to be present, explain: leaching pits, number leaching chambers, number: leaching galleries, number: leaching trenches, number,length. leaching fields, number, dimens,ons. o,erflow cesspool, numb Z>— Al;ernahve system. IJA Name of Technology: Commen:s ;, to C nc�i,on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, et . A: Ic CESSPOOLS: ,ioute on Site plan) Numper and configuration: (� Depth-top of liquid to Inlet invert y T Depth of solids layer:__ AA Depth of scum layer, ka D—ens,ons of cesspool._ AA ' v.ater,als of construction: 1 ino'cahon of groundwater Al ,nflo- icesspool must be pumped as pan of inspection) Comments :note conCition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: )/ 'cote on site plan) M.iterials of construclion: D:mens.o-, Dep,n of solids _ — Commen's note condit,on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, el- , D.9. a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SS � PART C Centerville CornerSYSMZ OI P!E&6.-�J ON (continued) Property iddress: Sout�i Main Street ---- �� Owner: Centerville,Mass. Date of Inspection: Jef f Komenda 4/28/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: j inc ude ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where publi Ovate/ wpply cne into house) I Gr J�-O- 0 y lrwu.c Cc/25/97) Page 9 of 10 I� ��s� _�� '�I � 1 / % �`. i T /� \ /� �,� . � �+ � ' U E.` � � t � j; / i �C n c, � �� ' I Yy . � � \ � :r`i ,� ��. I I �' ` i =� y �-- � w_ -- ( � N k �-�-- � �/ �-a �h , �/' � y,s / ` �� L� 99 � � � 0� ��i �� i.i 7 �� 3'- \ �w / � � �� i � � �, ;�� _� .y. � ri 4� � '�� :.�� I � i f • SUBSURFACE SEWAGE DISI SYSTE•vs INSPECTION FORtis SYSTEM INFO; Ov tcontlnued) Centerville Corners Motor Lodge Proper. ^�"eSSSouth Main Street Centerville,Mass . ° Jeff Komenda Date of insaect 4/28/98 1 Dean to CGounowater�p Feet Please :nc:ca,e al! the methods used to determine High Croundwa'C( Eli, 6 on. / OO:a;nec from Design Plans on record �Qose,.ai,on of Site (Abuning propersy,� bservauon hole, base menr s-ma etc ) k-"De.emine it from local conditions C ne" —:r) local Board of health p-mp,ng records ccal exca.ators. nstallers Sc -SCS Data Desc, oe - •c).)r own words how you established the High Grouncw-xer::evallon. Must be complete,'; Installed and repaired septic systems at this location. Water was not encountered at 16" Used Water contours map. Gahrety & Miller Model 12/16/94 (....r.-.r-I--n:.rr- e-r-.�-n mrr..r..r.,rr,:-.r.•.+vr*:-r.•-•en.--.-re-tiz:r.x�..-r.rr.. - ... .. _ -.. - as-c•r.-Rrr_�-.-r-T----T- 11'OHN OF Barnstable BOARD OF HEALTH S011SURFACF SEWAGE DISPOSAL SYSTEM IN311FCTION FORM - PART D - CF.RTIFICATIO'1 -T r.. •r+�-rs �ra-r-nrrrsrri+rr:rrn-rors�vr rsm r.•r-rrrrr<r m+rr�r•,-.-r^ r - -TYPE OR PRINT CI.EARLY- PIZOPERTY INSPECTED Centerville Corners Motor Lodge STREET ADDRESSgn„th Main RtrePt Centerville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # b2`01b OWNER ' s NAME Jeff Komenda PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sc1fi 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City Stat. t I P COMPANY TELEPHONE ( 508 775 - 3338 FAX (508 1 790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and complete as of the time ofeinspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : ��SystemsPASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with 'Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . W V Inspector Signatur Dated One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the I)OARD OF II EAL7'lI If the inspection FAILED , the owner or "operator shall upgrade the eyetem within one year oC the date of the inspection , unless allowed or required otherwise as provided in 310 CHR 15 . 305 . partd . doc C ' r w s s THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Dircctor of the ion ut Water Potlution Control