HomeMy WebLinkAbout0020 THREAD NEEDLE LANE - Health (3) 20 Thread Needle
Centerville
A= 210-085
/V EM A D
No.2-1 s3LOR
UPC 12SU
• waft IM USA
1�
OISFI
Town of Barnstable
Inspectional Services Department
BARNSTAr r
MASS. ' Public Health Division
039. gyp'
0 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 8388
May 28, 2021
MOORE, CHERYL A & ANDREW, STEVEN PAUL
20 THREAD NEEDLE LANE
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 20 Thread Needle Lane, Centerville, MA 02632 was
inspected on 05/11/2021 by Douglas A. Brown, certified Title V Septic Inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Liquid depth in cesspool is less than 6" below invert or available volume is
less than V2 (hall) day flow.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas kcOT , CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\20 Thread Needle Lane Cent.doc
{ _
A
VC-Imm
` t
�\ r • COMPLETE-THIS • ON•
ELIVEPY
■.Complete items 1,2,and 3. A. Signature ❑Agent
■ Print your name and address on the reverse X ❑Addressee
so that we can return the card to you. C. Date of Delivery
■ Attach this card to the back of the mailpiece, B. Received by(Printed Name)
or on the front if space permits.
r 1. Article Addressed to: _ __ _ D. Is delivery address different from item 11 ❑Yes
F delivery address below: ❑No
MO ,CHERYL A&ANDREW, STEVEN PAUL
1 _ 20 THREAD NEEDLE LANE
s CENTERVILLE,MA 02632
❑Priority Mail Express® '
l� ----
OI I I�IIII IIII III I II II I I I I I I IIII I I I I II II I I III ❑Adult Signature ❑Ris Registered Mail TM
El Adult Signature Restricted Delivery ❑Registered Mail Restricted.
❑Certified Mail® Delivery
❑Certified Mail Restricted Delivery ❑Signature Confirmationrm
9590 9402 6702 1060 1005 19 ❑Collecton Delivery ❑Signature Confirmation
Artirle_Numher_CTransfer_from service label)_-
Collect on Delivery Restricted Delivery Restricted Delivery
Mail
7 015 1730 0001 4987 8388 O)il Restricted Delivery
PS Form 3811,July 2020 PSN 7530-02-000-9053 Domestic Return ReceiptTZ
P
-'3Z-5•ZZl3'�- ZZ�? la 0 z e e t"T 0 9 z 0 :n53
GHvmNQ_i os. ansvNin
e� U3SS32{GOV SV 21EVSBAI120 1QN
t aaaNgS ni. NNni3m
1 ztsil90 a t a� szg aaxzN
-
'IfiVd NaAJI.S `1AJX(I IV 79 V-Ik2IFIII3i axoow
r -
t zoz sz ,kdw sv t scs0000
HEQ L96h T000 OELT STOZ ^
96'900 $ Mb
Q 609Z0 dIZZO I09Z0 VW`Sruuz,fH rFw+o3jd
0 •6Cq�
• �e�—p T f/mcl&4'U A laauS UIEW 00Z �'319tllSNHYB
® uoiSfnTQ 1111BOH Dllgnd .o
C S3M08A3N11d<<30bf1SOd S71 alge;suaug 3o umoj,
- - -- -
�� _
��
'� t
i
r
ti�
r
F
l
I[k�
hi {{ ss
if 1 11 .1 S1. ,.� V4 t ��l•.V�ti� s t+l 1� � 1.l'ti:lt �-
i
• ~
•
_� __.. _a. _ _._�- -�
1,"�,�,�...>`� -, �__
�.
,.
i
�tHMEr Town of Barnstable
Inspectional Services Department
HA ASM
MASS.AS
M Public Health Division
039.y
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 8388
May 28, 2021
MOORE, CHERYL A & ANDREW, STEVEN PAUL
20 THREAD NEEDLE LANE
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 20 Thread Needle Lane, Centerville, MA 02632 was
inspected on 05/11/2021 by Douglas A. Brown, certified Title
V Septic Inspector or the
State of Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Liquid depth in cesspool is less than 6" below invert or available volume is
less than V2 (hall) day flow.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
'Ea
Thomas kcea , CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\20 Thread Needle Lane Cent.doc
a THE rph
Town of Barnstable
meet
B" mAss r� g Inspectional Services Depart
f639• ��
A,FD � Public Health Division
200 Main Street; 1-iyannis MA 02601
1 humas A McKean. nV)
{)Mice 509-862-4644
FAX 509-790-6304
Feb 6; 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code 361e failurde criteria and associated(r(epair deadline.
An "x" marked in theoist
Nischarge
DAY DEADLINE CRITERIA round
or ponding of effluent to the surface of the g
Pumping more than 4 t►mes during the last year
r not due to clogged; €
ed or obstructed
❑
pipe. gged SAS or cess pool
❑ Backup of sewage into the house due to an overloaded or clo }
❑ St
ructurally unsound septic talk or SAS
ONE 1 YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box ►s above the outlet invert due to an
overloaded or clogged SAS or cesspool
w the high groundwater elevation
u A portion of the. SAS, cesspool. or privy ►s below €
o A portion of the cesspool is located within a Zone 1 to a public well
e wate I-
ppi
A portion of the cesspool is located ��ithin 50 feet 1ern if the water)analysis
kith no acceptable water quality alalys►s. 1 1 h►s _) passes
indicates the well is free from pollution).
TWO 2 YEAR DEADLINE CRITERIA
❑ Single Cesspool
o Any `conditionally passed systems" (broken cover; relocation of a pipe; relocation
of a driveway due to 11-10 components; etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per town
Code §360-20 h)
y, }� —
►�„�_� �.►`e�1-I�._i.n_GeL'1�u�1 f��Qi'— 12 ALI Aw
Repa►r deadline._
Q\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS doc
Commonwealth of Massachusetts
aio-o�s-
�n I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name /
required for Centerville ✓ Ma 02632 5-11-21
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.
Important: A. Ins ector Information Q
When filling out p S� 4t-
forms on the
computer, use Douglas A Brown
only the tab key Name of Inspector
to move your D.A.Brown Inc
cursor-do not
use the return Company Name
key. P.o Box 145
Company Address
Centerville Ma 02632
Cityrrown State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
5-11-21
pec or'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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
I-P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v
20 Thread Needle Ln
Property Address
owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^ � 20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
r: I� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components-pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El Z 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 facilityor dwelling inspected for signs of sewage back u ?
9 9 9 P
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3 per
assessors
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
according to as-built card this system consists of 2 cesspools and a leach pit
Number of current residents:
D residence
Does es Bence have a garbage grinder. El Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
l- Title 5 Official Inspection Form
�1° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^ � 20 Thread Needle Ln
v
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Cesspools appear to be original leach pit was installed in 1991
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�m l Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�m ��F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4�
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�m ,�-p Title 5 Official Inspection Form
�1° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 2 in series and 1
pit
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
rn i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2 in series and 1 pit
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspools were in poor shape with deterioration on the cement blocks leach pit showed signs of
failure at one point.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
v�
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�. �1� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: greater than 4
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 20 Thread Needle Ln
Property Address
Owner Moore
information is Owner's Name
required for Centerville Ma 02632 5-11-21
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
'Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE
LOCATION ck hrey(d n-4td DLO SEWAGE
VILLAGE Vj JL4 ASSESSOR'S MAP& LOT
INSTALLER'S NAME& PHONE NO. r,keE( A&(>Cy,O�
�
SEPTIC TANK CAPACITYY
LEACHING FACILITY-(type) QQC =(ft�'� (size)
NO.OF BEDROOMS PRIVATE WEL BL1C WATE���
BUILDER OR OWNER —T-o
�16N A4_LArCjL,,,q DATE PERMIT ISSUED: , --:% " P/
DATE COMPLIANCE ISSUED: r'' - /Q/
VARIANCE GRANTED: Yes No
S h
c tss a
i
https://town.bamstable.ma.us/Departments/Assessing/Property_V alues/HMdisplay.asp?ma... 5/12/2021
Assessing As-Built Cards Page 2 of 2
https://town.bamstable.ma.us/Departments/Assessing/Property Values/HMdisplay.asp?ma... 5/12/2021
` Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
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.
A. General Information
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name .
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433
Telephone 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
9/12/12
Inspec s Signat 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.
l (`� ON I
20 Thread Needle Ln.doc•03(08 Title 5 Offici In Ilion Form:Subsurface Sewage Disposal System•Page 1 of 15
y Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 20 Thread Needle Ln.
Property Address
Moore
/ Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Pumping suggested every 3 yrs to prolong the life of the system
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
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
20 Thread Needle Ln.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
city,Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
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
C). Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing,to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
20 Thread Needle Ln.doc•03toa Title 5 omclal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.).
C) Further Evaluation is Required by the Board of Health (cont):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply.well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the.analysis must be
attached to this form.
3. Other:
n/a
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
0 ® 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 '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ E Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
20 Thread Needle Ln.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should.contact,the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of'a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
20 Thread Needle Ln.doc-03f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
qM
20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ 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?
0 ❑ 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)]
20 Thread Needle Ln.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
W Title .5 Official Inspection Form
e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7M 20 Thread.Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): n/a Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15..203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
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
y Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe): n/a
20 Thread Needle Ln.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
D. System. Information (cont.)
General Information
Pumping Records:
Source of information: Pumped approximately 6 months ago per owner
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):
Cesspool to block pit to precast pit
Approximate age of all components, date installed (if known) and source of information:
cesspools 1966 per age of home, precast leach pit 1991 per BOH file
Were sewage odors detected when arriving at the site? ❑ Yes ® No
20 Thread Needle Ln.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2'feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: N/A
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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
20 Thread Needle Ln.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville . MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3 yrs to prolong the life of the system
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
n/a
Dimensions.-
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
n/a
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):
n/a
20 Thread Needle Ln.doc-03(08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 15
I
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�qM 20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 0202 9/12/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
n/a
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
20 Thread Needle Ln.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments,(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
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
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
System is comprised of a block cesspool to 2nd block leach pit to 3rd precast pit. The 1st serves as a
tank. The 2nd block pit is dry at this time,the 3rd precast pit is also dry with stain line at the midway
point of sidewall. No indication of backup all w/covers to 6" of grade
20 Thread Needle Ln.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
18"
Depth—top of liquid to inlet invert
Depth of solids layer
12"
Depth of scum layer trace
Dimensions of cesspool 6x6
Materials of construction block
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool equipped w/ outlet T, cover to 6"of grade, no indication of backup
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.):
n/a
20 Thread Needle Ln.doc•03t08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�qM 20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a.sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
O
C �3
C,� � � �
a a,
20 Thread Needle Ln.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 20 Thread Needle Ln.
Property Address
Moore
Owner's Name
Centerville MA 02632 9/12/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water .
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: >12'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
Checked with local excavators, -
❑ avators, installers (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
per elevation of home to nearby surface water
20 Thread Needle Ln.doc-03(08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
1� TOWN OF BARNSTABLE N
LOCATION hv�c�d ° SEWAGE #
VILLAGE ( U ASSESSOR'S MAP 6: LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY �o - -c's .6
LEACHING FACILITYAtype) We --{,osQ— (size)
(04
NO. OF BEDROOMS _PRIVATE WEL UBLIC WATER
BUILDER OR OWNER A( rC ,LJ
DATE PERMIT ISSUED: ►-
DATE COMPLIANCE ISSUED: i6' �
—t
VARIANCE GRANTED: Yes No
h
S h _.
ol
Guess 1,� Q
J
No......!/:--1_.r� Fss...3.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Disposal Works Tonstrnrtiun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( —an Individual Sewage Disposal
System at:
.......... .---•--------------C�_.320 .(.....................................................
Location-Address or Lot No.
............................... ..................... .......
oUW
FWD7 .,�.�._LI.. .. `.�................. ......... .�..1. 6 Ad .......................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___.3..................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building __-_.--•-- No. of persons............................ Showers — Cafeteria
G4 Other fixtures ---------------------------------------------•----
W Design Flow.._....J5...�....................gallons per person per day. Total daily flow____-_�.........._............gallons.
Septic Tank—Liquid capacity............gallons Length_______________ Width................ Diameter---------------- Depth................
W Disposal Trench—No..................... Width_----____-_-__..__-- Total Length.................... Total leaching area........._..._.____sq. ft.
Seepage Pit No__ .............. Diameter...4.OiD......... Depth below inlet.......6.-.-.... Total leaching area..................sq. ft.
Z Other Distribution ox ( ) sing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1-__-_-_____-__minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
-----------------
•--------
---------
---------------
•--•-------------. ---------------
0 Description of Soil........................................................................................................................................................................
V ....---•••--•-•-----••••-•--•-•••---•••--•••-•--•--...•••••••-•---•-•-•--•---•••••--.....-•••-••-•-••-•--••-------•--•-•-••--••--•---••--•-•-•--••---...•-•--•-•--•••--•-.......-•--••.............•---
W
-- -------------
U Nature of R pairs or Alterations—Answer when applicable...___. .V........Q�N4�_......���f��.7_ "................
�.. 11/` .:...0 TF ------....0 �°�------------ ...........................................
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 has beeX�Z�
issued
Signed ........ ---- .........�--�--r....I7---�---
Date
A lication A0proved B --------------- J <cv, K-y... .... ... ......ff.-. e:..
Application Disapproved for the following reason.- ------------------------------------------------------------1.......................... ...................................... II
------------------------------------------------------------------------------------- -------------------------------------------------------- -------------------------------------------------------------- ---------------------------------------
-
Da
PermitNo. -----------f ' ----/-v�-6---------------_-- Issued --------------...................................................-
Date
sy !
-4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Dispaiial Workii Tomit ur#Uan firrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( -an Individual Sewage Disposal
System-at:
Location-Address or Lot No.
............................... ................... -- .................................................../ j
(l/ \�Addres� s441 t / "_j
Installer Address
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.........'5__... ....................gallons per person per day. Total daily flow.......O...................gallons.
W x Septic Tank—Liquid capacity............gallons Le tDepth idth-_:•_--�•:-•�_- D
-_.:-.
Disposal Trench—No_____________:__--- Width... iTotal Length Total leaching area _ :sq. ft.
Seepage Pit No_____ _____________ Diameter----`_ ____.___. Depth below inlet___..__-__-.... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---•-------------•---••............••---•-----•-••••.......-•----------•. Date...................................
14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water________________-___,__.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 '-•-•-•--•--••-•••--••••-••••--••---•.......•--•-•-••--•----•---•••••-•--'---------•••-•••-•......••...................................................
0 Description of Soil........................................................................................................................................................................
x
w
V Nature of R.pairs or Alterations—Answer when applicable.______,.�- .._,.__C�(ti ____• -S� Z •7 -................
.......................................
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 hasfbeen isyu-ed by the board of ealth. /
1' Signed " :`..... ........." . �!�6te �.--
- - -
Application Approved BY --------------- j--=---_---_---_--_---_-----................................
- ��...
• � �^ to
Application Disapproved for the following reasons- ............................................................... --------------------------------..................
J.................... I...---t--................--..........- .-----...........................................--............................................................. -----.-------- Date....................
/� ��ji
PermitNo. ............9/......1.... ....6;....--------...... Issued ........................... ..------------.--------.......------.e. +
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN'OF BARNSTABLE
Crrttfi ate of G1 #II IauT ra
THIS IS TO CERTIFY, That the Individual Sewage Disposal System eori tructed ( ) or Repaired
by........................... -------------�--{(�--��-/-----� ............................. -:-- -------------..........................----------------- ............
at -----.� ....................... - -r^, ...........................................................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ........, 7-./S�.6.....-- dated ...................................._-----.----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION'SATISFACTORY.
DATE L � . ... ...--�---------------- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �----
�j_� TOWN OF BARNSTABLE
No..................I�.� FEE s...�.....�...'_
Otoposal 10orkiidun #r r#i�ln Fermi#
Permission is hereby granted------......_-tA.� ?'� 1.. ,.......-•....................................................•--
to Construct ( ) or Repair (t._Kan Individual Sewage Disposal System
- .................... --`
Street QQ
as shown on the application for Disposal Works Construction Permit No,!1- �-10--. Dated..........................................
.................................. .................................................._
^Boardlof Health
DATE.............. r� �' , +
FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS —