Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0036 THORNBERRY LANE - Health
36 Thornberry Lane Centerville P A = 187 074 Aff No.2-11153LOR '`brrco�+s'a HASTINGS-UN Commonwealth of Massachusetts �., Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thomberry Lane Property Address Lisa Kinkead Omer Owner's Name Information is Centerville MA 02632 12-19-12 required for 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. Please see completeness checklist at the end of the form- Imng out t when rms A. General Information Q on l the comoputer, `���������1(NiOF 144 s;?i,��� use only the tab 1. Inspector ���� •s9�'y key to move your �O: •G cursor-do not ,fames D. Sears JAMES •:� use the return Name of Inspector key. Capewide Enterprises,LLC �, " �.•`a Company Nome ��� l�•.... G�`��. 153 Commercial Street '���i,awn . ram_ Company Address Mashpee MA 02649 Cityrrown state Zip Code 5508-477-8877 S1623 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12-22-12 t c pectoes Signature Date c The system inspector shall submit a copy of this inspection report to the Approving Atilttonty.' Boardrt of Health or DEP)within 30 days of completing this inspection. If the system is a shared systt or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shalAdubmilte report to the appropriate regional office of the DEP. The original should be sent to thr*51et owner and copies sent to the buyer, if applicable, and the approving authority. ra r co M ""*"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. (Sins•11110 Toe 5 omdai mspedton Fomc Subaufaoe Sawase Disposal Syalem-Page 1 of 17 Dec 24 12 01:48p p.2 f -7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thornberry Lane Property Address Lisa Kinkead Owner owner's Name information is required for every Centerville MA 02632 12-19-12 page. CityT town state 21p 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 16.304 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. Check the box for'yes","no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"ar 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 itis structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins,11110 TO 5 Official InspecLon Form Subsurface Sewage Disposal System•Page 2 of 17 Dec 2412 01:49p p.3 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Thornberry Lane Property Address Lisa Kinkead Owner Owners Name information is required for every Centerville NIA 02632 12-19-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): a r ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 15ins•S U1 D Title 5 Official tnspedion Fcrm:Suesurtaoe Sewage Disposal System.Page 3 of 17 Dec 2412 01:49p p.4 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 36 Thornberry Lane Property Address Lisa Kinkead Owner Owners Name information is Centerville MA 02632 12-19-12 required for every page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment:. ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: •*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in SDI is less than 6"below invert or available volume is less than %day low A MCy/.yl t5ins•11/10 Title 5 Offidal Impedion Form:Subsurface Sewage Disposal System•Page 4 of 17 Dec 2412 01:49p p,5 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Thornberry Lane Property Address Lisa Kinkead Owner Owner's Name information is required for every Centerville MA 02632 12-19-12 page. City/rows State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)_ Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to15,000 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 Il 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 GMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•t 1/1 D Tile 5 Oftal inspection Form:Subsurraoe Sewage Disposal System•Page 5 of 17 I Dec 24 12 01:50p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Thomberry Lane Property Address Lisa Kinkead Owner Owner's Name information s' required for every Centerville MA 02632 12-19-12 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done: You must indicate"yes or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? 1Z ❑ Was the site inspected for signs of break out? j� ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15.302(5)] Q. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 15ins-1 I/ti Title 5 01ficiel hspedon Form Subsurlece Sewage Disposal System•Page 6 of 17 f , Dec 2412 01:50p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Thornberry Lane Property Address Lisa Kinkead Owner Owner's Name information is required for every Centerville MA 02632 12-19-12 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal precast tank D Box and two pits 'Number of current residents: 4 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 d 2011-136,000Gal 9 y g (9p ))' 2012-134,000Gal's Detail: Sump pump? ❑ Yes f Z No Last date of occupancy: PresentDate Commerciallindustrial 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: !Sins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Dec 24 12 01:50p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thomberry Lane Property Address Lisa Kinkead Owner Owners Name information is required for every Centerville MA 02632 12-19-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA -- - Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 151rns•r VIC Tine 5 Official Inspection Fwm_Subsurface Sewage Disposal System•Pago 8 of 17 Dec 24 12 01:51 p p,g Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thornberry Lane _ Property Address Lisa Kinkead Owner Owner's Name informrequired tion a Centerville MA 02632 12-19-12 required for every page. City/rown State Lip Code Date of Inspection' D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: Tank and Pit 1984 and 1996 Permit # 96-345 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4' PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 2"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal precast Sludge depth: 2 [sins..t in D Title 5 Ofrniel Inspection Form;Suhaurface Sewage Disposal System•Page 9 of 17 I Dec 2412 01:51 p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Thornberry Lane Property Address Lisa Kinkead Owner Owners Name information required for every Centerville MA 02632 12-19-12 page. City[Town state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 12" 0„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 181. How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level wlout let baffle Tank and cover's at 2"below grade No sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 TNe 5 Official Inspection Form Subsurface Sewage Disposal System Page 10 0l 17 Dec 2412 01:51 p p.11 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Thomberry Lane Property Address Lisa Kinkead Owner Owner's Name information is required for every Centerville MA 02632 12-19-12 page. City/Town State Zip Code Date of Inspection Q. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•1111 o Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Dec 2412 01:52p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Thomberry Lane Property Address Lisa Kinkead Owner Owner's Name information is Centerville MA 02632 12-19-12 required for every page. Cityrrown State Zip Code Date of tnspWion D. System Information (cont.) Distribution Box(it present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 20"x2T-13" Below grade, Box is H-20 in stone drive way. Box is solid w/two lines out. Box should have speed leveler installs. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located, explain why: tsins-11110 Title 5 official Inspection Forth:Subsurface Sewage Disposal System.Page 12 of 17 Dec 2412 01:52p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thornberry Lane Property Address Lisa Knkead Owner Owner's Name information is required for every Centerville MA 02632 12-19-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 2 ❑ leaching chambers number- leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typeiname of technology: --- Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc,): Leaching is two precast 600 Gal pits w/4' stone. Pit 1) H-10 at 14" below grade w/8"water, stain line at 20", No Higher stain line or solid carry over. Pit 2) H-20 at 13" below grade, Pit is Full 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 L51ns-1111❑ Tile 5 Official InspacUen Form:Subsurface Sewage Disposal System•Page 13 of 17 Dec 2412 01:52p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Thomberry Lane - Property Address Lisa Kinkead Owner Owners Name information is required for every Centerville MA 02632 12-19-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): LSre.11/10 Title 5 Official iwac6m ram Subsurface Sewage Disposal System•Page 14 of 17 Dec 2412 01:53p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 36 Thomberry Lane Property Address Lisa Kinkead Owner Owner's Name information is required for every Centerville MA 02632 12-19-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal-System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ti3 O r -3 - 7� ❑; o6-3 - d o � l�1T 0 t5ins-t 1110 Title 5 Olrccial Inspection Form:Subsurtace Sewage Disposal System-Page 15 W 17 Dec 2412 01:53p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 36 Thornberry Lane Property Address Lisa Kinkead Owner Owner's Name information is required for every Centerville MA 02632 12-19-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar [] Shallow wells 9�/d Estimated depth t hig"h ground water: 11' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,.date of design plan reviewed: Date _._. ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: r Checked with local excavators installers- attach documentation [] Accessed USGS database-explain: You must describe how you established the high ground water elevation: Per past report and 1984 permit, No G.W. at 11' Bottom of pit at 5' Before filing this Inspection Report,please see Report Completeness Checklist on next page. 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 c:f 17 Dec 2412 01:53p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thomberry Lane Property Address Lisa Kinkead Owner Owner's Name information is required for every Centerville MA 02632 12-19-12 page. CityrTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file e5i—-1 ill Tdle 5 Official Inspection Fomt Subsurrace Sewage Disposal System•Page 17 of 17 I I December 21, 2012 Re: 36 Thornberry Lane, Centerville,MA My wife, Ellen, and I purchased the above named property on September 15, 1985 from Silvia& Silvia. The attached floor plan is an accurate representation of the number of bedrooms and the floor plan when we purchased the property. Sincerel , i f Robert B. Kinlin COMMONWEALTH OF MASSACHUSETTS Countyof Barnstable Date : December 21, 2012 Then personally appeared the above-named ROBERT B. KINLIN and acknowledged the foregoing instrument to HIS free act and deed, before me. l Notary Public Printed Name: ,8p_-lia"d My Commission Expires: 7 '�4ERNARbX•KLQTZ Notary Public- COMMONWEAITHOfMA$SACHUSETTS .` My Commission Exptros May 26, 2017 34 All I 1 I f i 1 l el I i I _ a, -I • I �. _� � ! � ; I ' � i i I f � 1 ! i I � t � l � ` I i C f i l } i l 1 . I ► , f I I I71 f f S j M ff i �� ► i ' I i I j i f i _ _j � � � I, � ( i f � � { i i � i i ! i I l ' { : ! 1 I I I / jI I a 1 ( I I 4 , 1 I V' TOn OF R RNSTARr 2012 DEC 21 F=j 3 02 Commonwealth of Massachusetts MI . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin = ;1I Owner Owner's Name information is Centerville ✓ Ma 02632 5-19-15 required for every page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information o (� 1 I I D on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gllfoy use the return Name of Inspector key. B&B Excavation Q Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 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 5-19-15 Inspector's Sig ture V I 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system. (Include laundry system Inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2013- 140,000gallons 2014-60,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): 2„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 4" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" 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 14" , How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Tank should be pumped for maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: j 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "t 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ' Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach co of current pumping contract(required). Is co attached? Yes No PY P P 9 PY ❑ ❑ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in working order no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M " 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 6'x4' ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit 1 had 1'6" of standing water at time of inspection and pit 2 had 6" of standing water. (both pits are 4'x6') Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�' 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ' 36 Thornberry Lane Property'Address Dawn & Dan Balkin Owner Owner's Name information is Centerville Ma 02632 5-19-15 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks orbenchmarks. Locate all wells within 100 feet. Locate where public water-supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately P O O A - 30' Aq - aa" 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: wet sand @ 132" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5-15-84 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i - Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Thornberry Lane Property Address Dawn & Dan Balkin Owner Owner's Name information is required for every Centerville Ma 02632 5-19-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4/12/13 Assessing As-Built Cards f TOWN OF BARNSIT LE LOCATION_(2 Lff-r u - Xt--7 SEWAGE# Y 3 VU CAGE Cto tit -6 r►i, I I ASSESSOR'S MAP&LOT !f 4 INSTALLER'S NAME&PHONE NO. 90 rz 9H C. SEPTIC TANK cAPACrry iwa• a ism s LEACHING FAaLrrY: (type)H:to z cp H.20 Lco (size) NO.OF BEDROOMS ^� BUILDER OR OWNER �8�i —t- �J,t.,c(/ PERIVII !TDATE: "it?. COMPLIANCE DATE: 7-2 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ' facility) Feet Furnished by 1 a.p a �s o / r vmw.town.barnstable.ma.us/assessingMMdisoay..asp?mappar=187074&seq=1 1/2 1e .f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC= ECEIVED F n � r tl 'q �< JUN 2 4 2002 TOWN OF BAR.NSTABLE HEALTH DEPT. t TITLE 5 t,�tt,t; i; OFFICIAL INSPECTION`FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ',;t PART A CERTIFICATION Property Address: 36 THORNEBERRY LN CENTERVILLE, MA 02632 `� ��� Owner's Name: LYNNE LAKIS Owner's Address: 36 THORNEBERRY LN CENTERVILLE,MA 02632 Date of Inspection: 5/20/02 _ Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 Telephone Number: 508-564-6813 FAX 5087564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Titl k:5(310 CMR 15.000). The system: , t X Passes, _ Conditionall.. P sses _ Needs Furt valuation by the Local Approving Authority Fails Inspector's Signature: ��[ Date: 5/20/02 xe 11.1_°f The system inspector shall sub mi 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. :a Notes and Comments SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the,system will perform in the future under llte same or different conditions of use. o0 n'MhFS i, Page 2 of I I OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 36 THORNEBERRY LN CENTERVILLE, MA 02632 Owner: LYNNE LAKIS Date of Inspection: 5/20/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectio►i D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 replaceni6t,.. Fepan,Sas approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over=2`0'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: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled'or uneven distribution box. System will pass inspection if(with approval of Board of ,Health): _ broken pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: n/a 's 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 ND explain: n/a , t Page 3 of 11i'I ^� OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -• PART A CERTIFICATION(continued) Property Address: 36 THORNEBERRY LN CENTERVILLE, MA 02632 Owner: LYNNE LAKIS Date of Inspection: 5/20/02 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 a. 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�tlie well wateranalysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fi•om that facility and the presence of ammonia nitrogen and nitrate nitrogen is,equal to,or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this;form. t k` 3. Other: n/ate + r s, 'i; • h; I ' S Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) U. Property Address: 36 THORNEBERRY LN CENTERVILLE, MA 02632 Owner: LYNNE LAKIS -' Date of Inspection: 5/20/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: 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 cverloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped TWO YEARS A(O- MAC OMRF.R 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 supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. - X Any portion of a cesspool or privy,is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water,quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.l (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails{ The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) IL yes no - X the system is within 400 feet of a surface drinking water supply X the system is within 16.0 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 11 of a public water su6,ly well If you have answered"yes"to.any question in Section E the system is considered a significant threat,or answered "yes" in Section U above the li�i'b s steiI ItaS.Fliiiled."I'he uwncr or Operator of any large SySlem considered a significant threat under Section E or failed under�Section D shall upgrade the system in accordance with 310 CMR 15.304.Tile system owner should contact the appropriate regional office of the Department. � !1 d 5 Page 5 of 1 I , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 THORNEBERRY LN CENTERVILLE, MA 02632 Owner: LYNNE LAKIS Date of Inspection: 5/20/02 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping informationwas 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? „A 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 dwelfin`g 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 maintenance of subsurface sewage disposal systems`? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.Fo'r'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 I t!: Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '! PART C SYSTEM INFORMATION Property Address: 36 THORNEBERRY LN CENTERVILLE,MA 02632 Owner: LYNNE LAKIS Date of Inspection: 5/20/02 tFLOW,CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR,j5':203 (for example: 110 gpd x#of bedrooms): 557 Number of current residents: 2 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(last2 years usage(gpd)):4* -6()- J'�j-tj Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a -,, ,,�ENERAL INFORMATION Pumping Records t Source of information: TWO YEARS AWO- MACOMBER BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons_-jl-Icw was,quantity pumped determined? n/a Reason for pumping: n/a •Y 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: 1984 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO A , I Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE"'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 THORNEBERRY LN CENTERVILLE, MA 02632 Owner: LYNNE LAKIS Date of Inspection: 5/20/02 BUILDING SEWER(locate on site plan) Depth below grade: 8" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 2" ji.. Material of construction: Xconcrete' :metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is agel'i36nfirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 71'',W 4' WIN" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top oftoe,utlet tee or baffle: 6" Distance from bottom of scum to bottom of cutlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Lh 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 Continents(on pumping recontinenda11tt�Vns, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,"etc.): 4 n/a ± 1 7 Page 8 of I 1 ! OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 THORNEBERRY LN CENTERVILLE,MA 02632 Owner: LYNNE LAKIS Date of Inspection: 5/20/02 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 i�metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a till Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) `t: !lift 1n' Pumps in working order(yes or no):'NO Alarms in working order(yes or no):NO Comments(note condition of pumpichanber,condition of pumps and appurtenances,etc.): n/a l� I e ei �y. R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 THORNEBERRY LN CENTERVILLE,MA 02632 Owner: LYNNE LAKIS Date of Inspection: 5/20/02 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: 2 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 t Type/name of technology: n/a Comments(note condition of soil, sigh's of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE LEACH PITS,APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 516" 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 . a PRIVY: (locate on site plan) Materials of construction: n/a F' f. 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 iw : 40 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 THORNEBERRY LN CENTERVILLE, MA 02632 Owner: LYNNE LAKIS. Date of Inspection: 5/20/02 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. al� C3 AA New ;to h'A I 63 15 8C 9 5,6 in Page I I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -.SYSTEM INFORMATION(continued) Property Address: 36 THORNEBERRY LN CENTERVILLE, MA 02632 Owner: LYNNE LAKIS Date of Inspection: 5/20/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local exca'va6rs, installers-(attach documentation) NO Accessed USGS database-explain: n/a 1 You must describe how you established the high ground water elevation: HAND AUGER- 10 FT. � 3 cI II TOWN OF BARN TABLE T_OCATION 6r-r SEWAGE # 3 ��✓ VILLAGE ��h � ( y► L� ASSESSOR'S MAP & LOT eZ" C) INSTALLER'S NAME&PHONE NO.-4--P IM 14CQ!h b e/' SDK SEPTIC TANK CAPACITY 111Da LEACHING FACELI'I'Y: (type) jj�L© (aCQ 14-,�U b00 (size) NO. OF BEDROOMS BUILDER OR OWNER 14 A ; ,S PERMTFDATE: "%" �� COMPLIANCE DATE: � :� " 5 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leas g facility) Feet Furnished by � �� __ ___ __ �" .�,� i T� a 1 � �n r` ;� .. <` �� � `'li ..� - �`�' p1 a v� , � � �-z® /� / I\-S ���` � ) � M � � � � �``, '` 0 �! No. (0-3 9� Fee $40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0.pplication for Mizpool 6potem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No.'7'7 1_8 49 6 36 Thornberry Lane Centerville,MA Stephen & Lynne Lakis Installer's Name,Address,and Tel.No. 77 5—3 3 3 8 Designer's Name,Address and Tel.No. 77 5—3 3 3 8 J.P.Macomber & Son Inc. j, Box 66 Centerville,Mass. 02632 J.P.Macomber Jr. Type of Building: Dwellinggg No.of Bedrooms 3 Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Me(li lim sand Nature of Repairs or Alterations(Answer when applicable)Adding an addItional nn gallon leaching pit to—a-p- exiSiting Tank &-pit Date last inspected: 7/2 5 /9 6 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 of to place the system in operation until a Certifi- cate of Compliance has been issu by this Bo d�7e Signed i Date 7/2 5/9 6 Application Approved by Application Disapproved for the following reasons Permit No. 96 --3Y—S Date Issued ��" x t ", .No. — Fee $40. 00, THE COMMONWEALTH OF MASSACHUSETTS - - � PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS 0ppYication fgMizpaar 6potem Conoruction Permit i Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: f Location Address or Lot No. Owner's Name,Address and Tel.No.771^8496 36 Thornberry Lane Genterville,MA Stephen & Lynne Lakis r, _ Mass , 02632 Installer's Name,Address,and Tel.No. 77 5^33 3 8 Designer's Name,Address and Tel.No. 77 5^3 3 3 8 J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 J.P.Macomber Jr. F Type of Building: DwellingXX No.of Bedrooms 3 Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures f Design Flow gallons per day. Calculated daily flow gallons. r - Plan-Date Number of sheets Revision Date Title Description of Soil ; mnd i lam gi4nd Nature of Repairs or Alterations(Answer when applicable)A ddin g sin .a�ri rl; t i a m 1000 D all or l�rhin git to an existingTankpit. - - Date last inspected: 71125,1096 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by this Bo d o He lth.- Signed 2' t Date 7/2 5/9 6 f Application Approved by Application Disapproved for the following reasons Permit No. / o--3 7--5 Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced�X)on by j P Vg,sgmbn,• T-" for StPnhen T,A.ki Q as 36 Thnrnharry T,a.na Cani arvi 1 A_MA gg, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No._�'4 —3 V-r dated_ 7~-oZ-S-- Use of this system is conditioned on compliance with the provisions s . h below: No. '""S Feed,,L1n.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS 'i9;po9;a1 *pgtem Congtrurtion permit Permission is hereby granted to J.P.Macomber Jr. ' to construct( )repairKXX an On-site Sewage System located at 16 Th nrnhArryy T,R n e Cant.arvillR _maaag , and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: 7 a _ Approved by G i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) y I� J.P.Macomber Jr. , hereby certify that the application for disposal works construction permit signed by me dated 7/25/96 , concerning the property located at T Th arziba ry I,&tee Centerville.Mass meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 4 feet or greater below the bottom of the leaching facility • and/or change in use proposed r i no increase in flow a p There s g P • There are no variances requested or needed. SIGNSE. : DATE: 7/25/96 LICE SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. z •I 1 . W- �� �► '. — j ~ 8 a'y w�*tE7" P-1mj g - V.."` ••�. — 'f' 'M' Y•.)•'9 _ /4- !fie• r•� �a 1 � � i 0 -Existing 1500 gallon tank. New 4' pit with 4' � xi of Esting Distribution box stone all aro xisting 4' pit with 41 stone i Q i 39 Thornberry Lane Centerville'Mass. y / No..... . � Fxs.......�.4. ri THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HE-A_1,,TH ••---Town..........................O F.........Barnstable.....................-----------....................-- Appliration for llhipwial Works Tonoirnrtiun ami# Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: ........Th°rnbe '........ Centerville ....................I_°t..._...................------------•.............._..........--•••--- Location-Address or Lot No. ---------• 9 -•------ ------ -------- -----•--...----•--•---- S i i yr ,�,---sz Znr�ae= - 6 9 i+�ain t address' - ------Centerville.......................................................•- s :.... - --... , Installer Address 30 $.70 Type of Building Size Lot.............•-_-_----------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons.....................------. Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------------------- - -- W Design Flow............................................gallons per person per day. Total daily flow...•.33D..............................gallons. WSeptic Tank—Liquid capacityl50.0..gallons Length..10.'.6°... Width.-5'$"•-... Diameter................ Depth-52.4........ x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No.....1-------------- Diameter.....1-4.......... Depth below inlet.....3_LZ...... Total leaching area....a15.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by....$axter & Nye --- Date......4/141.. 3.................. `3j Test Pit No. 1...2..........minutes per inch Depth of Test Pit....13.2......... Depth to ground water....1,32"- fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...... lit-OF O -� n ....."... ...... p`A. 'ROGER Description of Soil......Q-24_____loam..&_.suhsoiL�-.-24•_-72-.._max se_..aancly..graVe1 r...................... -•--'-PAUL N v .................................•...72 132"_medilml..sand_................................................................................... C2-JAICHWEWICZ W No. 20 .-•---------•--•-------------------------------•--------...........------------------•---------....--...-----...............--.....-----------.......•-••••..._............. .. IL U Nature of Repairs or Alterations—Answer when applicable............................................................... ........ ----------------------------•----------•--•----------------------...---------...--------.•....-------------------------------------------------------------•---- Agreement: " The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary de The and s' ned fu ier agrees not to place the system in operation until a Certificate of Compliance has be ued by th d of th. Signed...... -....... ------ ................................ /Application Approved BY ............ Dat �A f 1 ---------- ate Application Disapproved for the following reaso s:.............................................------•--•---••••••-•--•-•••••-•-•••......--•••--••••••••---.---- .............................•---•---•••••---•••-•--•-•--•-....•••-••---•-•••-•••-•-----•.....••-••••-••---..........-----••-••••-•---••-----••-•-•-•-••••-•-••-•-•••-••••-----••••••-•••--••••••-•---•- Date PermitNo...................................................... Issued........................................................ Date No.... ... ;V✓... r us.......`... THE COMMONWEALTH OF MASSACHUSETTS j BOARD OF H EA&H •.._p .......................00.........Barnstable.......... :...:. ApplirFation f ar_..PiiVvsaa1 Works Tnnitxnr#ion umit Application is hereby made for a Permit to Construct (X ) or Repaii ,( ) an Individual Sewage Disposal System at Thornbesx ! Circle .......... _.......... -•• ..Cer er i3 I e------- ---------------------'°'t-�D---...------ -................ --•--- •-- Location-Address or Lot No. ....--•--•--• ................ ` /may _ . y .... • .... S �V. -�,� erw- VC. s:C��s �1� a11t. Address W -------- 81 (3V �3---------------- W -----•------_ Installer Address t.,xl` r. � �' �- 30 870 S feet U Type of Building � Size Lot._.___.._!.............. q• t , Dwelling—No. of Bedrooms.................m.........................Expansion Attic ( ) Garbage Grinder kE§ .' Other—a Type of Building ............................ No. of persons.......................----- Showers .. — Cafeteria Other ............................. ( ) , fixtures -----------------------•• 55 Design Flow >, 330 W g ......................gallons per person per day. Total daily flow....,......_.................................gallons. WSeptic Tank—Liquid capacityj500..gal1ons* Length_.1016S_.. Width...5!.B.T.... Diameter................ Depth.5-!.4u:.: :. x Disposal Trench—No..................... Width.................... Total Length.................................... Total leaching area....................sq.'ft.. Seepage Pit No._I _____________ Diameter....1,4.�....... Depth below inlet.....3.,1 Z!__.. Total leaching area...U5-.......sq.,ft, Z Other Distribution box ( ) Dosing tank ( ) `-' Percolation Test Results Performed by------ Baxter & Nye Date.....A/1-4/83.................. 1.4 Test Pit No. I... ...........minutes per inch Depth of Test Pit...3.32_'!------- Depth to ground water___ 40 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water... �H OF. r -............................................................................... - P D Description of Soil..... " m &-__sue;-0raVe - ------------------ vx2"=132" tned:am__ nc1. ...................* ---•------•---- � M+eHAn�w�cZ � W -----•--------- ------------------------------------------------------------------------------------------------------------------•'-•... ca No.3042Q. U Nature of Repairs or Alterations—Answer when applicable.......................... ........................................... ..._ 8 Agreement: r, The undersigned agrees to install the aforedesc 'bed Individual Sewage isposal System in cordance ith b �Lf the provisions of TITU 5 of the State Sanitary od 3� The un n(A f her agrees not to place the system in / operation until a Certificate of Complftte has b sued by t d of lth. Signed •-•-- -- - •!••---------••••-•----•-•. ......... ................................ Datt Application Approved By--•--------. 1... ... .° .......................................... ---..... .(!.�/.. ......... Application Disapproved for the following reasons---------------------------------------------------------------------------•--•---•••-•-•-•••-•-•-•---••-----•-- ..........................•-----------------•-----•--------------•---•-----••-•••-----••----•-•----•....... Date . PermitNo.......................................... ------------ Issued......................................................= ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i Trrt firatr of TuntpliFanrr THIS IS TO CERTIFY, That t dividual Sewage D poP�Azem cons �ired ........••. by---------•----••------- L /f.... ............. : /'Installer at...................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLFei/Qf 3hs kate Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated`_........................................ _.,._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..---------•--•---..._--/l> L3-== 9 Inspector.........�-,�/-- -----------------•-----------•---•---•----------•--------••-. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EAL7- 4 ........................::.......OF..-----.............................-...-.. No.........-- 9.5°Y »,. FEE........................ i �anaa 1-�un lan mat Permission is hereby granted................................ j to Construct ( ) or Repair ( ) an Indivi ual Sewage Dis sal.S stem . W at No. _.._.. ._.......... � 0t ?'4' . Street as shown on the application for Disposal Works Construction Permit D;())....�........ Dated.......................................... DATE_ -t— Board of Health ............•• ............................. S FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LOCATION SEWAGE PERMIT NO. Xa l /f e�-r� VILLAGE INSTA LLER'S NAME A ADDRESS B U I L D E R OR OWNER :GATE PERMIT ISSUED DATE COMPLIANCE ISSUED /O 23 - 8y ` � 7 V"" 'r� .� � �� � �� � C4 i ,�\� � t � , ,, rt� ' r W / d E .f � 1`. r, jaro xisting 1500 gallon tank. New 4'with 4' xisting Distribution box ofstone a xisting 41 pit with 4' stone s � � QT� 3Y Thornberry Lane Centerville,Mass. It 7v , 511 t'. TOWN OF BARNSTAB E All] 7 ZQlq All] 14 /^/ L - 7 �D V `i a ft p V C S p d n( C L J L _ S L s Z {— A v note: ' bui1G[n f5 Wall bzfOr removing exUS[in)Wall Fold�nq ironing bo,.rd y .. a 3 O — a I .�. O �' LF � u l Ic�TGNEN O L--I Foldlnq co�n+cr w+p slice l„e.. ........... P I.�nen Gab�neF Ly bulllzr 1 + Y .. I O tll Q r I : W �n s� M J� Z � f• 3 3 'U # m O +- QJ m GAP-A4E VJ d J � � J n O Z W L O• n � mm f T a FLOOR-PLAN m , :5ovc� F� '^3 S Fhe mhorn.+fu n,.l Fe•.ldentt,.l Gc•de'2 009 ��_�S;',11 _ 0 _ ^J o "3• f� G 'a c All h-res^re�nenr�ar����nens�,,,,s.r�+� - be-.i+e,mr;f iaJ L•y Gene r:.l Gi n+r:.c+ur a^� r E 7_7 L' _ � J ao j. m w i a `c Rdr,LJ DRAWING TYPE Flrsl'Flocr Plan +' SHEET NUMBER: A 2 00 y �cov�m o Q Z p ai C 0 7 0 � C Z NP E c L __ °o ° i nrnG ----- ------------------------- ---------------------------------- I L arnG n n All ekiz+i:,q�yligl:+s+o r AS 1! (—Wild teifnq wl'ere wesese 9 —1 Q 5 .. �. (L : :.�.J i � d : : : p ' e 5 O1— /c y 6er>�oorl p r�N Z o u s` �«.. I O �I � z� .�. °d n IF ---------- - :: p w 6� Z _ 1. — go 0 Cf1 J Q' m J 3° 0. i KING 6— Q ' n m w Q --------- — -- � -- — -- -- ���-- — -- - �q�hEGON�FLOOR-PLAN \ - AMU mu p ' b mc O 3 Exizrinq walls .{3 �O x-m O 5.� New w.11s [v-`T III _ � - �moa� c- c TI'is^1.+ w..z�e-.ignn!ii att:rJtme wi}I� m°O°L 3 O F va Q +I�ci+ern..t'v,ns!Y=azidan}i,,l G:.lr[00'J �n •' N C�- El'i c,I Ov J+I:MAW, ^`Ell .Q L E u Z T j N:'re. �ffi All rye-,r meni.POimzn-.,ens..re+u '`o Lie si+e ucr',ficJ by Gencr,.l Go:.rratF.+r V v v all, .#+fine of tun-.+Na}iow J OS mole Oe.+ec+nr DRAYYING TYPE: 2�Gond Floor Plan a SHEET NUMBER: le L tK,t iL. REVISIONS: TEST PI T DA TA DATE CF rEs ri NG _/- -- 4-- PERC. TEST DATA : SEPTIC TANK DETAIL : SIZE- GAL. DIST BOX DETAIL : LEACHING /� '_'!CITY DETAIL: _°tof,� TEST BY i A,AN7 � r r• ���ci r DATE OF TEST/NG 4 � ?` QNn TO l c.N. O M, O r/ tt .5 REOU Ht t b S O CON RM TO f 5 Rf` _ 1 ) c R r T M ' F� � �.,.�•� '-i T_,`s� F Yl�Tc. �"� y: ,. � �,I�. / f W1 TNESSED BY -_. TEST BY JT t lt7i t r is �•. ;t.. t?'r ��• . €`� � F NO. OF OUTLETS _ Y_ W/TNESSED BY 4,4, �; �'�t�.--��° REM0 Pf,4 s'LE COO E \ r v,• . -o-L ' 8ROUGH r T f — . :. ;✓�` ice' _. •f i I I , �. y l•• - 1 ;a 6P4DE - : 2,.PEAS TgNL Lc�CMBF/L 4 ' SLig 1t_ l4.f j i I � ,• _ 3 CL�R - -- ., �dl+' __ c _.IvrtE ' _s_._'_ i ---_- _ 1 Lam"__ _-•-- --__ _1, _`�� _ _ -. -~ "6 L MIN 2••M!N F IN ' _ 4S REQUIRED DEPTH OF rES r _ , i RAE T 1 L£ EL O MIN )UTE tE l .. / x T y _-l_ �d I r I r I � ., i5�. } i 4 �i JR VEL } j i f C•/. _ _GAL R I /NLET AND OU7LfT �••� •7' O - MINIMUM OUTc.fT TEE CfEf'TH 1 T I I P?X TAAW I �« ---- „ TEES TO 8E rAS7 L/pL/ta f- /4'"AT 1 I0010 DEPTH OF a P EGAST OR 8LG1L�( F JJ ,. � _.. ._�.J` ONS UC � SEEPAGBE' P/T IAON, SCHED 4G^ �' 9 � �6 C`ONCRL Ti I t R � DEPTH OF TEST i . , , p _ • + , PLACE'CONCFrE rt 4 6 C TR TAW' 1 MtN I • • ` I __— CGW,'RErE 80TTOM ON LEVEL STA8LE8dSE I I RArE 34` 8' % CONS + t (W4TERrjGHr' Lf TEf PRO V aEU WHERE ScO t Lj =-, •` •I OF INLET P/P£ EXCEEDS o o6 `1. op TAN/! TO 8t 481.F TO W;TH.S-AV/) - -- ---- -- - i ---- _ ' IM OF T�11( ON L EVEc S'4Q(E IaAS 'N A Ot/4!PE l .S�STfM _ rt � H ID LIIAa�'NG UNLfSS�rNDEk - 8D AftN / { + !/ WASME0 STONE' 13.z £ S. 0 I t PA Ohl VE. H Ec 104 D 1 NG UNDER PAVEMEN' .;A- NO TES : PLAN VIEW INVERT ELEVA T/ONS� -- i THiS MAN iS FOR THE DESIGN AND CONSTRUCTION OF THE SEWAGE 015P O.SAL FAC I L/ T Y ONL Y. SCALE / - /NV AT BUILDING — • <<� 1 AL L CONSTRUCTION METHODS AND MATERIALS SHALL CONFORM T' _ lNV AT SEPTIC TANK(/NJ MASS. D E 0.E TI TL E 5 A ND THE Z ri ;; r` t 1�,: BOARD OF _ - _ x. IN AT SEPTIC rAN•K(GUT) 14 o9 HEAL TH REGUL A T IONS. L. _. / 4ic "' c ,L c c ?T'�1t'.3L �f= W- ti T H � f 11teLC+ cL_ Jf� _ i . H- Z ? t�,�4Tt'N /JCL. F.W�'ls' /�'/ n,g ;t-tAtC/. B +� ' ..INV Ar015T BOX(/Ao ar. �e•J w• Co.rsc.c.�ii: /_Iri.er0r 4- c.. +�} •'> �' 4r, IN ArD1ST BOX uT) � v i or' e c_.►s•.r y1 .e4.4.i vw*t f, /V xe "Aia., .0,qq �✓3 !n/V:Z�/ 8 3 .�v.uCo e0c 4 rv�T �` 7 R/ .E't'� i2 +�• . ✓T $ YS .ov src G �r✓,e . .' GJf•i 'G /'sK'.c7ay.+vk$ y'_: __`_�_A T LEACH/NG FACJL/TY I '�• `�_ C?. Lf . .`v>t+d.•f j<sr A� y .tt.. "JG j! /GJv�++ 'J�5 s=.'T /+✓V ^"'FJ+ / ?ifaebSi' GJr+'" C ]rs*r`r, ts`v ".,'<H s --- --- _7 ! BOTTOM OF P/T_� '�t- .> =4 i•yb... +4'+ fal3 TQ: 7% +t'?e•'. :i!x'r rGI✓Y 7y Fes.f�l ?!aT ry /tiy.', : i,' .v ly,�'•. G. a.v.0 'r<©?' C.ionN r9d.� S G= .Rrd" //'t/TG-, F•ta c:...v:"if�l? NJ OWO' j \k ` , suvia & Silvia j f Associates, Inc. - b G'N /J�4 T�4 • 9 n Street �t a1 tr 775-14.4� .. -� _ • l 1 °� __ Centerville, MA DESIGN FLOW =:. r ( � .�-` '-�oi=--�''"k- -;c,-._�--. • 1 ( CAPE CODSURVEY •� I CONSULTANTS t " 1 r 1 _ Enterprise (617) 775-7155 ' 76 Ent ise Road I �1E ,•' Ems , �, / 1� 1 ` REQUIRED SEPTIC TANK Hyannis, MA 02801 I61 7j 775 7815 el ►.i 7 �.; 'TA1 R5 SEPTIC TANK PROVIDED GAL .:�T 2q' � �'��v�' ��� REQ�I/RED S/ZE LEACHING FACILITY 1. 4- ' 1 , Y�G s 'D 4�i E.L E,u, . i<,'.' ►`� - p .•_ ' _ ,, vv,�: - z A r'�', w Ilk jJ r[ SIZE OF LEACHING FAC T Y PRO DED ' :* j 1 PE OF SYSTEM .- 4 , J TYPE Y TEM v�l� sit- TITLE. .n SEWAGE DISPOSAL SYSTEM Lo •`j_ t` DESIGN jo • !I_ t:v l ~(':.-. J...,P "'` wr R••x'e�.1 _d b t"+,.5 4 S + ay -- LOCUS PL A 0;/,00-0 FOR ocu* t • i V C�t�TA C ti�E \ = L�� .:r- 1 SCALE AS SHOWN METERS - FEET 0 jA DATE: t . - _ ;, ,•' 91 4 .w t � �- /r!. . / Y...1 l SIGN. ir1� r, _'� �'• COMP /DE CHECK t (��: 7- ! f_4IZ � DRAWN: • FIELD- ,. k-,�x J pr, 3 FILE NO. DWG. NO: .; J03NO: . :_ i SHEET: i OF: