HomeMy WebLinkAbout0052 THREAD NEEDLE LANE - Health 52 THREADNEEDLE L ., CENTERVILLE
A
Ill_I JAKECYci{otoy
UPC 12534
No.2-153LOR
HASTINGS. UN
� O
A,1 clyou.
�? THE COMMONWEALTH OF MASSACHUSETTS
E®ARD %HE LTH
. pphration for Disposal Works Tomitrnrtinn .
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: �['{ .. .--- .-- .. _
-... ..
........ c ion-Ad ess -a
b &
W O n gy �. Address
Ins alle Address �J T
Q Type of Building Size Lot.. ,���__IC-I'_----
er ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ___________________•-_-____-__ ._
------------•-----------------------------------•-
W Design Flow.......................�U_._.._... _gallons per person per day. Total daily flow............ ..10`�_ __-_____--__gallons.
Ix Septic Tank i-•Liquid capacity/gallons Length................ Width_............. Diameter---------------- Depth________-____---
x Disposal Trench— o.___.••_•-•_•-_--___- Wid h_________ _______•- Total Length__._....._ Total leaching area--------------------sq. ft.
Seepage Pit No____________________ Diameter.---- Depth below inlet..... ._ Total leaching area�.._.�. .sq. ft.
-
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by..........................................................................
Date----------------------------------------
,.a Test Pit No. 1................minutes per inch Depth of Test Pit--------------------- Depth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground
-
water________________________
a ............................... -- -------- - .-------
Description of Soil-------------------- ---- - -----------
V --------------•-•••---••---•--•-•-•-•-•------•-------------------•-•--•-• ------•-------•---•-•-------- -f-�--------------'----------....----------------------------------.....------
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee 's ued by lie board health.
Sid. -------- -------------------- Date
Application Approved By------. ............ .......•.--•--• / .�-------
Date
Application Disapproved for the following reasons:---------- - --------------------------------------------------------------------------------------------
----------------------------------------------------------
------------------
Date
PermitNo......................................................... Issued........................................................
Date
No.---.................... ........"... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
Qe
.....OF.
..... �.. 1.................. f a
Appliratiun for Disposal Marko Tunutrurtiun Prrutit
Application is hereby made for a Permit to Construct (1) or Repair ( ) an Individual Sewage Disposal
System at
_ ' - .---.-----•-------
.�
-..... LcatonAs
1� ----------------------- -------
Owner Address
Installer Address
Q Type of Build Size Lot._2 0 � Sq. feet
U Dwelling No. of Bedrooms-._--___•___-•_- --------------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixture
W Design Flow............................ ..........gallons per person per day. Total daily flow.............. ----------------gallons.
WSeptic "tank Liquid capacity �.gallons Length................ Width---------------- Diameter---------------- Depth_________-_--__.
x Disposal Trench— o________________ Widlh____._... __._______ Total Length........ -.____._-_ Total leaching area_;-__-_-- ..sq. ft.
Seepage Pit No..................... Diameter_ ._. __ Depth below ii_let____............... Total I acht g area --____� .___sq. ft,
Z Other Distribution box ( ) Dosing tank ( ) _ <�rf� /// U _
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_______________-___-_--
f3� Test Pit No. 2................minutes per inch Depth of Test Pit___---_-•----___�_- Depth to ground water__-_-___----_...___-_-__
• --
D Description of Soil................................... C �_. b' a
U -------------••------•-------------------------•---•----•-•--•--•-----••--•--•••-••-------•--•------••-•----...V-----------------------------------------------------------------------------
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------I___-__-________-
------•------------------••••-•-...----------•----••---------.------•--•----•---•-••-•-••---......--•------••---• --------.-----•-----------•------------------•------------.----------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bessued by/theb oard o health.
Si d .� ;i i r>rf�;l em, �..
ate
Application Approved By_...._
Date
__,>' ,_________. _ L�- :_ �-
Application Disapproved for the following reasons_________________________
-------------•----------------•------------- -------------
.. ...•••••---•---••--•-•-•----•••--•-•--------------------••.
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f••• �..........OF....... .. .......................
Tntifiratr of Tiluttpliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
y r� tall
nstaller
Z7
r•• V .t..�w
________________________ '0-b_^ __._ X ______.._................_.........._..........
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......... ............. dated-__._ :�_�7 _.._____....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
. DATE-----------•---•-------------------------------------------------------- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
w.
No.
2.0 ........... ..... �...........OF....- .....-:....-.. ................... .. '
Diapaa ial Markii C5nmitrurtiun fv>rufit
Permissionis reby granted.--............................................................................ --------------.............. -•------•------•••--- •-•.....---
to Constr "ct (/ r Rep ai ) an In ividual S A -e Dis 1 System s
a'�
at No. fit° _ __r. 'f . �"�' '
Street .✓.�_,...�
as shown on the application for Disposal Works Construction Pe No._________v� ated_____ _____!_/_____.._:_________..
"e�%lG e f
� ��
---•---•-• -==---------•--••--•--------�•--------- r-------•------••-•-- --•--......-.............
Board of Health /
DATE.................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
JuA814 07:55p p.15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owners Name
information is required for every Centerville MA 02632 "A 4
page, City/Town State Zip Code Date of Inspection
Inspection resutts must be submitted on this form. Inspection forms may not be altered in any
way. please see completeness checklist at the and of the form.
Important When A. General Information
filling out Prins ^��o
`` �uullt+nrrnru
on the computer, ,(vim( ������ �H OF A"'4SSq'��.
key to use move our the tab 1. Inspector:
cursor-do not DAMES 'R,
use the return James D.Sears =�;
key. ? Name of Inspector
CapewideEnterprises,LLC o •��
Company Name '. S -��`
153 Commercial Street
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
k
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
6-6-14
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000_gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""*"This report only describes,conditions at the time of Inspection and under the conditions of use
at that time.This inspection does not address how the system will perform In the future under
the same or different conditions of use.
151ns•,3113 Tills 5 Ofr 1 ion Form:L
age Disposal Systam•Pape 1 or 17
Jun 08 14 07:55p p.16
r
44 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
information is required for every Centerville MA 02632 6-6-14
page. Citylrown state Zap 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):
Uins-3013 - i
Title 5 Official hispedion Form Subsurface Sawape Dlsparal System•Pepe 2 0!17
I
un 081408:12p p,1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
information is required for every Centerville MA 02632 6-6-14
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):
a
❑ 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•3113 i Tide 5 Ofical inspection Form:Srbmrfam Sewage Disposal System•Pape 3 of 117
Jun 08 1408:12p p.2
Commonwealth of Massachusetts
Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Fonm -Not for Voluntary Assessments
" 52 Thread Needle Lane
Property Address
Sue Lamastro ,
Owner Owner's Name
Information is required for every Centerville MA 02632 6-6-14
page. Cdyrrown State Zip Code Date of Inspection
B. Certification (cons)
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 aseptic tank and SAS and the SAS is within 50 feet of a private water
supply well.
i ❑ 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 A
❑ ® 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 is less than 6" below invert or available volume is less
than %day flow;C Fdelll C
t9ns•3113 Tltle 5 Oflldal kEpealon Form:subs ofam Sewage oLVosal system•Page 4 of 17
i
Jun 0814 08:13p p.3
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
information is required For every Centerville MA 02632 6-6-14
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 collform 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.
El The system faits.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
❑ El 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
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.
15ins-3113
,. Tile 5 Official hispeclion Forth:Sibsiafaoe Sewage Disposal System•Page 5 of 17
i i
Jun 08 14 08:13p p,4
Commonwealth of Massachusetts
Title 5 Official, inspection Form
Subsurface Sewage Disposal,..System Form-Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
Information is required for every Centerville ! MA 02632 6-6-14
page. City/row 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?
x
® ❑ 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
availabie note as NIA)
® ElWas the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were ail 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) 1310 CMR 15.302(5))
D. System information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310#CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
l:
,i
Mine-3/13 4life 5 Official hmpevion Form:Subwi face Sewage Oispasal System-Page a of 17
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Jun 08 14 08:13p p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
information
required for every Centerville MA 02632 6-6-14
page. Cityrrown State Zip Code Dale of Inspection
D. System Information
Description:
The system is a 1500 a Gal.Tank D Box and six infiltrators.
' Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ' ❑ Yes ® No
Seasonal use? ® Yes ❑ No
201248,000Gals
Water meter readings, if available(last 2 years usage(gpd)): 2013-35,000GaI's
Detail:..
9
Sump pump? k ❑ Yes ® No
Last date of occupancy. Present
° Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatslpprsons/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-3f13 Title 5 Oftal InXwOon Force:subsurface sewage Disposal system-Page 7 of 17
ti 4
Jun 08 14 08:14p p,6
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner owner's Name
information is required for every Centerville { MA 02632 6-6-14
page_ chyfrown 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: 2011
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for um in
P P 9•
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)
❑ InnovativelAltemative 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):
tSins-3113 We 5 Orfxial trspectan Form:Subwfaca Sewage Disposal System•Page 8 or 1 7
Jun 0814 08:14p p.7
Commonwealth of Massachusetts
Title 5 Official., Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
information is required for every Centerville MA 02632 6-6-14
page, City/Town State Zip Code Date of lnspeetlon
D. System Information (cunt.)
Approximate age of all components, date installed(if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 40"
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: 30"
feet
r.
F Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
L
If tank is metal, list age: years
4
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 Gal. Precast
Sludge depth:
1"
t5ins•3N3 Title 5 Official k"ection Form:Subsurfam Sewage Disr+owl System•Pepe 9 of 17
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Jun 081408:14p p.8
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owners Name
information is required for everyCenterville MA 02632 6-6-14
page. Cityfrown 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 on
Distance from top of scum to top of outlet tee or baffle 8
Distance from bottom of scum to bottom of outlet tee or baffle 18"
Asbuilt-Tape
How were dimensions determined? 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.Tank at 30" below grade wlcove's at 1'. in and out let tees. No sign of
leakage or over loading.
t
i Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
J
❑ concrete ❑ metal' ❑ fiberglass ❑ polyethylene ❑ other(explain):
I
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
tsins!•3113 Me 5 O1fierd Inspection FoTm:Subsuiace Sswage Dtsposa!System•Page 10 of 17
Jun 081408:15p p.g
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro r
Owner Owner's Name
information is Centerville MA 02632 6-6-14
required for every
page,. Cityfrown 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.):
- i
I
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
r
❑concrete ❑ meal ❑ 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.):
I
M
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
r j
15ins'•3113 We 5 Official Inspection Form Subststace Sewage Disposal System•Page 11 of 17
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Jun 08 1408:15p p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
1WSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
information is required for every Centerville MA 02632 6-6-14
page_ Cityrrown 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.):
z ,
D Box is 16"x16"-2' below grade. Box is clean and solid w/two line's out. No sign of over loading
or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
I
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc,):
i ,
If pumps or alarms are nofin working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
3113 Title 5 Official InspeGion Fours Subaafaw Sewage Disposal System-Pape 12 of 17
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Jun 08 14 08:15p p.11
Commonwealth of Massachusetts
Title 5 Official -:Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
Information is required for every Centerville MA 02632 6-6-14
page_ Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
type: !
❑ leaching pits number.
® leaching chambers number: 6
❑ 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.):
Leaching is six infiltrators. Ck D Box and camera out to leaching. Leaching chambers are clean
and wet. No sign in box-line or chambers of over loading.
k
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
T
Depth of solids layer
Depth of scum layer i
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ft•W13 Title 5 offidal trtspWion Form:Subsurface Sewage Disposal System•Page 13 of 17
Jun 08 14 08:16p p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.' Form-Not for Voluntary Assessments
,
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owners Name
information is required for every Centerville MA 02632 6-6-14
page._ Clyrrown State Zip Code Date of Inspection
D. System Information' (coat.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: J
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
1
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l5ins 3/13 Title 5 Offidel Maspe Aien Farm:Subsurface Sawaga Disposal System+Page 14 of 17
i
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Jun 08 1408:16p p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
information is Centerville MA 02632 6-6-14
required for every
page. cityrrown State Zip Code Date of Inspection
D. System Information ,(corn.)
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
32' F,,4R _
�3-c2 - 33
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3
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t5ins an 3 Title 5 Olfidal UupecSan Fwm"audace Sewage Disposal System-Page t S of 17
4
Jun 08 1408:16p p.14
Commonwealth of Massachusetts
Title 5 Official.-Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
_ a ,
52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
information is Centerville MA 02632 6-6-14
required For every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
5 ❑ Check cellar
s
❑ Shallow wells
20'
Estimated depth to high ground water: feet
5
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
USGS
You must describe how you2establlshed the high ground water elevation:
Lot high abutting lot drops off 12+". USGS WELL AIM-247 at 23'ADJ AT 20'. Bottom of leaching at
4' below grade.
x
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Before filing this Inspection Report,please see Report Completeness Checklist on next page.
f5irm•,3113 Title 5 Official InspecOon Form Subsurface Sewage Disposal Sysiem-Pe"19 of 17
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Jun 08 14 08:17p p.15
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 52 Thread Needle Lane
Property Address
Sue Lamastro
Owner Owner's Name
informrequired
is Centerville MA 02632 6-6-14
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A B, C, D, or E checked
, 4
® 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
3
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t5fis 3113 Tills 6 Official Lrispection Fam SuCsurram Sewage Disposal Syslem•Page 17 of 17
TOWN® OF BA.RNSTABLE z
LOCATION S� 1 Ka[ePf�l eeff lP N SEWAGE # �-
VILLAGE..NAAttVt (C ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. " 1c)H
i
SEPTIC TANK CAPACITY
[5 nS
! LEACHING FACILITY: (type) (size) K l S
NO.OF BEDROOMS 3
rr
BUII,D OR OWNE - u(ZZ-
PERMITIT DATE: COMPLIANCE DATE: (/
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i
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Fla,
/ eQ
O
O -VV9A,
TOWNe OF BARNSTABLE
LOdATION :Q _M ffl_ozdPi .ed1P ry SEWAGE #. 99 �1
V11E,LAGE &,J1��(/1,U C ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. h 4�T7
SEPTIC TANK CAPACITY ! ~
is KS
LEACHING FACILITY: (type) 6 t (size) 1 K l S
NO.OF BEDROOMS
- BUII.D OR OWNE - &-_WLC
PERMTTDATE: COMPLIANCE DATE: t/
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 leaching facility) Feet
Furnished by
VIC -S 4,
of
Da
of
t7 , �3
1 .,
I
No. / Fee i f
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pphration for Migpo.5af bpotem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System` &Individual Components
Location Address orJ of No. e Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
2!0 D S �h {irii
Installer's Name,Address,and Tel.No. Designer's Name,Address Tel. o i-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs orAlterations(Answer when applicable)/ 4110i-'e S Pp�i �� Z
l-a 4i at�f i tr v h
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y s oard ofj4eal
Signed Date /-5" —9 c7
Application Approved by Date /2,
Application Disapproved for the following reasons
Permit No. Date Issued ��''
ri
No. ^" 4J Feed
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
.,_ . Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplicatton for Migpogal &pgtem Comaructton J)ermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System "dividual Components
Location Add ss or of No. Owner's Name,Address and Tel.No.
T / ,.pa� time le
Asses/6a 0 YA
Installer's Name,Address,and Tel.No. Designer's Name,Address Tel.N;15-
o F
Type of Building:
Dwelling No.of Bedrooms Lot.Size *sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations Answer when applicable)' A110 L-Y 5�r7' e- /G /� 7
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation.until a Certifi-
cate of Compliance has been issue y is oard of, a�.-
Signed Date 1.2 "g
Application Approved by < < Date 12, 1- .:FL
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(L )
Abandon d( )b � � D
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Pe 2 dated / ,'; 1
Installer Designer j
The issuanc of is ee all not be construed as a guarantee that the sys wi unction as designed. i
Date �(/ Inspector v�_�, it .
IV
— .. __ _
No. _
—�n�1�---------- ----------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Iigpogat OpOem Congtruction Permit
Permission is hereby granted toCons5uct( )Repair( )U7�ade( Abandon( )
System located at ,�.�CTM� /0� / '`e 4 zv
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of tth'i'�,-e1mit. _
Date: �� Approved by' - � -
r'
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED BOARD OF HEALTH
nst conserva 'on 7artrfient
WN OF BARNSTABLE
i ned tr 4 tt or Bi-tipwial Work.5 Tomitrur#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X� an Individual Sewage Disposal
System at:
..��
\.IA•Qia V�S..........Lacatio.l._ .
.........
------------
Owner j �`ir/��.lS Aaa s .
i.....................! tr .
---------------- J�1 cT Q �/ �
Installer Address
Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms................,.—?-------------------._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons-----------................. Showers ( ) — Cafeteria ( )
dOther fixtures .- -----------------------------------------------------------........----•-------------------------•-------•...............
W Design Flow.............. ------------ per person per day. Total daily flow........... '--------_-------_.
--------gallons.
WSeptic Tank—Liquid capacityl.U910---gallons Length________________ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. -------I........... Width.....&.____._._._ Total Length.-_- ........ Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter-------------------- Depth below inlet-------- Fr Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------- --------------------------------------------- ------------------- Date........................................
Test Pit .No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' ---------------------------- ...........
.-.-.-.-------------
--......
.-------------
•..................
-......
..•--•-----------
0 Description of Soil........................................................................................................................................................................
w
UNature of Repairs or Alter ions—Answer when applicable.____L.M_ :__._.___, ..____ L� �-8..
..------•. Ajc
- ---------- ��
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as een issue y t oard of health. �f
Signed ------.... /���................. .- ..-------
Da
Application Approved By , . ...:' .,-
--:...-.. ....�... -- — .............. ---......... ....................................
Date
Application Disapproved for the following reasons- --------------------- ---------------------------------------------------------------------------------------------------------------
. .......... . . ........................ . ------------------------ -------------- ------------------...-.-.....-.......-----------------------.- ........................................
Permit No. % �/'. ............_......_.......... Issued ..........� ......` "' �!
Daze
{
-�
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE, t
- ry .cal ltr#ion r Diva uiitt�� � l Mnrl;ii To$ts#rur#tun PPrutt#
Application is hereby made for a Permit to Construct ( ) or Repair (<) an Individual Sewage Disposal
System at:
..... .....-•-.....-•---••-•---••--•-•-•-••......•----•......•-••--•---
Location- \ddress or Lot No.
< , C'& v�,s 5 7r4?/LZ4-.3 yUc �ULC_ /,dc1 _ -`
................-.._...........--•--••.... -•-••---•---•---------•-......---...•...... ..........................................
Owr" Address --------- -
ddr. se s ....................................
W 79 .. "7 .P�•j Z.Vc��..��.J �� .------.....�--�-. y----• G / -'=��......'1''1 t . t�S
a
Installer Address
UType of Building Size Lot............................Sq. feet
I-, Dwelling— No. of Bedrooms.................I-------.------.---------Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building
a, yp g ............................ No. ofpersons
-.---------'_------•........
--• /.- Showers ( ) — Cafeteria ( )
Other fixtures . '
W Design Flow.................5.. ..............gallons per person per day. Total daily flow�.........17�___ ..............gal Ions.
WSeptic Tank—Liquid capacity&q�...gallons Length---------------- Width------------ Diameter_.............. Depth................
x Disposal Trench—No. .......(........... Width.....Cn........... Total Length..../.4.......... Total leaching area....................sq. ft.
Seepage Pit No...-...._.. _---.-. Diameter-------------------- Depth below inlet--------1.F=_: Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------............
Test Pit No. I----------------minutes per inch Depth of Test Pit......-.-.---------- Depth to ground water......---...............
f14 Test Pit No. 2................minutes per inch Depth of Test Pit...--.--....--...... Depth to ground water....--..................
a' ---------------------------------------------------------------
---------
•----------------
-----------
-----------
•------------
•.....
-••••••--------------
...•--
0 Description of Soil........................................................................................................................................................................
W
V •...
•---
-------------------------------
•------------
•--------------------------------------------------------------------------------------------------------------------------
•-----------
•------
W
U Nature of Repairs or Alterations—Answer when applicable.....i-! 1.5T•4(a_---------- -------
.! =< a_:.'.Z>t'TGfiS•-.
------------............ "'T - --••-••. -•-••-.....-•------•-S--'-d........-----------------...----...-----------------------------....._........•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has%eeen�issue by the-board of health.
Signed ... .�Y✓1.. 11------- /' cn .... ..� �/��.....
Application Approved BY L --�-��� ..(_" _�..�'';�............... .................................... . .... ...... ................................ -
vDare
Application Disapproved for the following reasons: ................. ........ .... ........................ ..................... . . .................
---------------------------------------------------------------------------------- ------------------------------------------------- --
,�... Date
Permit No. .- - - ... Issued ........._::�)......' Cam' "...�"--h/ ....."I
....._------'- --------------- Dare
-------.---_—.----.--.—.--,----.--,--.—.------- --.----------------------------.----.—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Q-Tex tiff ate of C�umptianve
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
y.................................................. Installer
at ............... 5. ........ 1'`�rC �a1.CQ i 4. 1_..... f .: I%..............
. ........
the application for Disposal Works Construction Permit No. f ,r�''�... �.y ..... dated
has been installed In accordance with the provisions of TITLE of The State Environmental Code as described in
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT'THE
SYSTEM WILL FUNCTION SATISFACTORY. r'--
DATE....... ' � �.._ .. ....... ............. Inspector - :--.......
---___-_ _,- --------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS /`j
BOARD OF HEALTH
7 TOWN OF BARNSTABLE
No..... .....•... = FEE.........................
Dtupusal Workii Tunti#rnr#iun "permit
Permission is hereby granted--_--_-----_---.?�������-�J i.?.-/.........---� -C�,11�i.....!...=.../o►-�
to Construct ( ) or Repair an Individual Sewage Disposal System
at No. - a� ....................'Ft za0...-....-------L✓.......----G
Street --4-"-
as shown on the application for Disposal Works Construction Permit ". � �.� Dated._-_ . ..................
---------------------=----
Board of Health
DATE........ ...!---� `
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
rf0c)- AT10N
` TOWN OF BARNSTABLE
✓r,l- SEWAGE # QV�226
VILLAGE ASSESSOR'S MAP & LOT aZ/Cy•OS;X
INSTALLER'S NAME & PHONE NO.,/�o�,,(,/dam,' Cc��rrsr5�w�h®w 9Aa-M.26
SEPTIC TANK CAPACITY 1, 00 6-41
LEACHING FAC1LlTY:(type) -drW A-, bas Q) (size) 6 X/F
NO. OF BEDROOMS PRIVATE WELL OR P LIC WAT
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 5 17 9y
-r
VARIANCE GRANTED: Yes No `�
3 /
o Gr,
J
TOWN OF BARNSTABLE
LOCATION 5J �NREAD /NEkDLE L,�1-A/r SEWAGE #
VILLAGE C—
t,�7'E�V/LSE ASSESSOR'S MAP &&LOT
INSTALLER'S NAME & PHONE NO. ��� �"''4CaWI
C
SEPTIC TANK CAPACITY D O d -
LEACHING FACILITY:(type) / c00 oaxvj (size)
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE
BUILDER O< OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
v RL9p Y
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