HomeMy WebLinkAbout0006 TOMAHAWK DRIVE - Health 6 Tomahawk Drive, Centerville
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UPC 12543
No.... 53L.OR ItZCOW
HASTINGS, MN
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs ✓�N E��FD
Department of � oFe� 8 -199?
Environmental Protects roml��
William F.Weld xe
Governor 6' V S�entary
Arpeo Paul Celluocl 8 Slruhs
u.Governor B.CO Struhs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 6 Tomahawk Dr, Centerville Address of owner. Carl Lindberg
Date of Inspection: 1 —6—9 7 (If different) 91 Depot Rd
NameofInspector. W.E. Robinson SR PO Box 305
Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 W Harwich, MA 02671
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-:Zs
disposal systems. The system:
`
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: /f,
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYS PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
tyes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exffitration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
Printed on Recycled Paper
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 Tomahawk Dr, Centerville
Owner. Carl Lindberg
Date of Inspection: 1 —6—9 7
B)SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution boa is due to broken or obstructed pipe(*)
or due to a broken,settled or uneven distribution box. The system will pas*inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution boa is levelled or replaced
The system requu*d pumping more than four 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
C) THER 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 the
public health,safety and the environment.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
9) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddr,esm 6 Tomahawk Dr, Centerville
Owner. Carl Lindberg
Date of Inspection 1 —6—9 7
D] SYSTEM FAILS:
1his1ave determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for
determination is identified below. The Board of Health should be contacted to determine what will be neomary to correct the
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E]LARG SYSTEM FAILS:
e following criteria apply to large systems in addition to the criteria above:
system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
h and safety and the environment because one or more of the following conditions exist:
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 H of a public
water supply well)
The owner r operator of any such system shall bring the system and facility into Rill compliance with the groundwater treatment program
requutmen of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addrom 6 Tomahawk Dr, Centerville
Owner. Carl Lindberg
Date of Inspection: 1 —6—9 7
Check if the following have been done:
lz puntping information was requested of the owner,occupant,and Board of Health.
(/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
ZAs built plans have been obtained and examined. Note if they are not available with N/A.
V The facility or dwelling was inspected for signs of sewage back-up.
V The system does not receive non-sanitary or industrial waste flow
The s' was inspected for signs of breakout.
syste components, excluding the Soil Absorption System, have been located on the site.
j/Th'e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
material of construction, dimensions,depth of liquid,depth of sludge, depth of scum.
Thee an
d location of the Soil Absorption System on the site has been determined based on existing information or
a roximated by non-intrusive methods.
_The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddresd: 6 Tomahawk Dr, Centerville
Owner. Carl Lindberg
Date of Inspection 1 -6-9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow:.AL6LD joons
Number of bedrooms:2--c/
Number of current residents:
Garbage grinder(yes or no)-A,c7 _
Laundry connected to system(yes or nor S
Seasonal use(yes or no):_
Water meter readings,if available: 1996 - 41 , 0 0 0 g a 1 s. 1 9 9 5 - 4 6, 0 0 0 g a 1 s
1994 - 38, 000gals.
Last date of occupancy:,--q
COMMERCIAL/INDUSTRIA U
Type of establishment:
Design flow:_gallona/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yea or no)_
Water meter reading, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
• A,e-- bo G—Q/ i-o/Z lfiL�w �✓S
System pumped ds part of inspection: (yes or no)_
If yes,•volume pumped: -o gallons
Reason for pumping: 46,/t%e t J 16
TYPE OF PYSTEM
ptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)/�O
(revised 11/03/95) ii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 Tomahawk Dr, Centerville
Owner. Carl Lindberg
Date of Inspection: 1 -6-9 7
SEPTIC TANK-_Z
(locate on site plan)
Depth below grade:
Material of constriction: ►Z==ete_metal_FRP_other(ezplain)
Dimensions:
Sludge depth: _
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 6
Distance from top of scum to top of outlet tee or baflle:,_(Z
Distance from bottom of scum to bottom of outlet tee or baffle:- U
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,$opth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) <5 9,0/ bs.K G rCj
G E TRAP:_
(k�ca on site plan)
Depth low grade:
Material of construction:_concrete_metal_FRP_other(e:plam)
Dimensi
Scum ess:
from top of scum to top of outlet tee or baffle:
Distance m bottom of scum to bottom of outlet tee or baffle:
Commen
(recomm ndation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
eviden of leakage,etc.)
(revised 11/03/95) g
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 Tomahawk Dr, Centerville
Owner. Carl Lindberg
Date of Inspection: 1 —6—9 7
TIG OR HOLDING TANK_
(locate site plan)
Depth grade:
Mate ' of construction:_concrete_metal_FRP--other(explain)
Dime na:
Capaci Dons
Design flow pllona/day
Alarm 1:
Cc nts:
(co on of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: 6
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, )
PUM CHAMBER:_
(locate n site plan)
Pumps working order:(yes or no)
nts:
(note 4on of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: 6 Tomahawk Dr, Centerville
Owner. Carl Lindberg
Date of Inspection: 1 —6—9 7
SOIL ABSORPTION SYSTEM(SAS): Z
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number:_
leaching chambers,number: 3
leaching galleries,number:
leaching trenches, number,length:
leaching fields,number, dimensions:
overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure, level of pondding,condition of vegetation,etcJ .3 � a
S l eh ,D d 1 G/4* m��� r 7 0 �- s�•a
CESSPOOLS:
(locate on site plan)
Number and configuration: bWt �r"r
Depth-top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer: f IV
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
P
( on site plan)
Mate ' of construction: Dimensions:
De of solids:
Co nts: (note condition of soil,signs of bydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95) g
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddresa: 6 Tomahawk Dr, Centerville
Owner. Carl Lindberg
Date of Inspection: 1 -6-9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmark#
locate all wells within 100'
LAJ
3�
3�1
� J �
DEPTH TO GROUNDWATER
Depth to Voundwater: 12'±' feet
method of determination or approximation: W61c,
(revised 11/03/95) 9
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TOWN OF BARNSTABLE
LOCATION to I DM4&Wk M✓6 SEWAGE# 26 -to 9
VILLAGE Cf-r-AE2 411 ASSESSOR'S MAP& LOTAO-61
INSTALLER'S NAME&PHONE NO.40M Er,-Oh S�01✓�FtL `775-V 7 7fo
SEPTIC TANK CAPACITY 1,500 5+
LEACHING FACILITY; (type) (size) .2 x (a.aS
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMIT DATE: /1•a 6 ` 9C, 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
o
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LU
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3y' 36
4L
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No. �` Fee $50 . 00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for �Digponl 6pgtem ConMruction Permit
Application for a Permit to Construct( )Repair(xx)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. 4 3 2—7 3 8 5
6 Tomahawk Dr, Centerville, MA Carl Lindberg
Assessor'sMap/Parcel PO Box 305, 91 Depot Rd, W Harwich, MA
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
WM E ROBINSON Sr Septic Srv.
PO Box 1089 , Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
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 gravel
Nature of Repairs or Alterations(Answer when applicable) Installation of 1500 gal . tank,_
D—box, and 4 #330 stonepacked cultex infiltrators. .
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 ode and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this ard,4 Health.
Signed lei t Date/ ��
Application Approved by �.,�.,._ �� Date
Application Disapproved for AV following reasons
Permit No. Date Issued
No. ' Fee $5 0_0 0
" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
9PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MA�SACHUSETTS
1
Application for Migpogar 6pelem Cortgtructio�.Vermit
Application for a Pernut to Construct( )Repair(xX)Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. 4 3 2—7 3 8 5
6 Tomahawk Dr, Centerville, MA Carl Lindberg
, <
Assessor'sMap/Parcel PO BOX 305, 91 Depot Rd, W Harwich, MA
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
WM E ROBINSON Sr Septic .Srv.
PO Box 1089, Centerville, MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
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 gravel
Nature of Repairs or Alterations(Answer when ap licable) Installation of 1 500 gal. tank,
D-box, and 4 #330 stonepacked cultex inf trators. .
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 ode and not to place the system in operation until a Certifi-
cate of Compliance has issued by this and Health.
Signed l/l� t f Date! 7 C•
Application Approved by — � Date .'1
Application Disapproved for the followmg reasons v
3
Permit No. �� 6 Date Issued
.r----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
Lindberg BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( X )Upgraded( )
Abandoned( )by Wm E Robinson Sr, Septic `Srv.
at 6 Tomahawk Drive, Centerville, MA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.� ��.�9 dated
Installer Wm E Robinson Sr, Septic Srv.Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date 7 Inspector 1
4 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Lindberg 1-1/
&9;pogal *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair(Xx)Upgrade( )Abandon( )
System located at 6 Tomahawk Drive, Caetervi lle, MA
Y WM E Robinson Sr, Septic Srv.
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.
I
Provided: Construction must be completed within three years of the date of this permit.
Date: I? _' r� ^ / Approved by
Zz-
NOTICE: This form is to be used for the repair of failed
septic systems only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAI.
WORTS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I,William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated /;2-aB"mot , concerning the
property located at 6 Tomahawk Drive„ Centerville, meets all
of the following criteria:
* There are no wetlands within 300 feet of the proposed septic system.
* There are no private wells within 150 feet of the proposed septic system.
* The obseved groundwater table is 14 feet or greater below the bottom of the leaching facility.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
r
SIGNED: DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 42
(Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification
plot plan,this plan should be submitted).
6
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' TOWN OF BARNSTABLE
LOCATION 6 -dM417d► 1t M✓E SEWAGE # yr; 4409
VII;LAGE CENfERt�rIIE ASSESSOR'S MAP& LOT
INSTAL LER'S NAME&PHONE NO.<<►.1 s bioa�'io sEggE�L 7 75•V 7 7L.
SEPTIC.TANK CAPACITY 1 S o o S+
LEACHING FACILITY: (type) (size) .?►rt l c aS
NO:OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: - a ' 9L COMPLIANCE DATE: I- G—97
Sep#406n Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Pr; :oteWater Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edgi:of Wetland and Leaching Facility(If any wetlands exist
:.within 300 feet of leaching facility) Feet
Furnished by
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