HomeMy WebLinkAbout0063 VALLEY BROOK ROAD - Health 63 Valley Brook Road
Centerville P
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A 188 160
No. 4210 1l3 ORA
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No. �f/; r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in co puter:—te_�
_ Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZI.pPficatiou for Misposaf *pstem Construrtiou 3permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) . ❑Complete System ❑Individual Components
Location Address or Lot No. 61 ✓4,//Y- V®&,k ✓4 Owner' Name,Address,and Tel.No.
Assessor's Map/Parcel C Piv+ f_v✓pe f �� uc� 1 e c /?
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
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(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. L-•
Description of Soil
Nature of Repairs or Alterations(Answer when YKcele, C.ce
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 d'rTMo plau the cr m operation until a Certificate of
Compliance has been issued�thisBoard of Healt Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. —J l Date Issued
No. c.lL J "" Fee
r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ye
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
�pIitation for 0sposal �pstem Construction Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. t/k//Y y 1�iocA4 Y<,I/ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel C �_r ✓ /�C ���� �` „ (Jyii f 0 G, 4/ T`
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
01611 0 b" Sev-✓ .11-t 0 r0.t'
G S
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(min.required) gpd Design flow provided gpd
Plan' Date t 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)
e
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 t to place the s n-operation until a Certificate of
rr
Compliance has been issued by this Board of Health.
,.<7�
Signe7:�
Date
Application Approved byr Date
Application Disapproved by Date
for the following reasons y
Permit No. 'fin/ — / Date Issuedbq
THE COMMONWEALTH OF MASSACHUSETTS
�C BARNSTABLE,MASSACHUSETTS
( Certificate of Compliance
THIS IS TO CERTIFY that the On-site Sewa Di I system Constructed( ) Repaired( ✓� Upgraded( )
Abandoned( )by 07
at 43 oz-//'C y /o v,k Y-C has been constructed in accordance
with the provisions of Titlee55 and the for Disposal System Construction Permit No. �- dated
Installer ejrI -6 Designer
#bedrooms�— Approved design flow gpd
The issuance of this pe it all not be construed as a guarantee that the system will fu cti tio` a j designed.
Date ( Inspector _
No. � f ( Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction Permit
Permission is hereby granted to Construct( ) ReZq
�y Upgrade( ) Abandon( )
System located at ��//t y 0
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction in a completed within three years of the date of this permit
Date Approved b
5/9/2019 AsBuilt
G 3 U v 7!
LocATI�oT� /3 �A«EYi�$[WAGE rERrlr No.
_v LLA$E
C FA.lFU LliL Lf
INSTALLER'S NAME L ADDRESS
•GILDER OR M'NER
DATE /ERMIT .ISSVED
DATE COMPLIANCE ISSUED , ! ��
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d
v
5C
4N v+
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issgl2/intranet/propdata/prebuilt.aspx?mappar=188160&seq=1 1/1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,,
63 Valle By rook Rd co
Property Address r"
Estate of Eleanor Braun
Owner Owner's Name -r3
information is Ma 02632 5/8/19 x ,
required for every Centerville
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:When filling out forms A. Inspector Information I-v- ( ssoa
on the computer,
use only the tab Michael DiBuono
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key.
35 Content Lane
raa Company Address
Cotuit Ma 02635
Cityfrown State Zip Code
508-364-9587 SI 13522
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
I spector'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
,ip Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. Cityrrown 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:
System contains a 1000 Gallon septic tank as well as a" New"concrete distribution box and a
concrete leaching pit.
2 System Conditional) Passes:
Y Y
❑ 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 indicatingthat the tank is less than 20 ears old is available.
Y
❑ 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
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. CityrFown 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 -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. Citylrown 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:
"Yes" « »
must indicate Yes or No to each of the following for all inspections:
You g _ p
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
Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
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 'h 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
9 Y 9 Y Y Y
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
p Title 5 Official Inspection Form Y
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is
required for every Centerville Ma 02632 5/8/19
page. Citylrown 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 sy
stem in accordance with 310 CMR 15.304. Th p9 Y e 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?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
Inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
n Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. City(Town State Zip dCoe Date of Inspection
D. System Information
1. 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
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ 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
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available last 2 ears usage 128 GPD
9 ( Y 9 (gPd))�
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
S
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
U
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
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: Not provided. Recommend pumping
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
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:
Original to home
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. 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: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
System is vented at the roof line.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
30"
How were dimensions determined? Tape Measure
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 is at normal level. Pumping is recommended
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
�% 63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. CityrFown 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
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
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 co attached? ❑ Yes No
PY ❑
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert New on 5/9/19
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.):
Replaced at time of inspection
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. City/Town 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:
Leach pit
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ 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
Title 5 Official Inspection Form
Jo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. City/Town 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.):
No sign of failure. Working g eas designed
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
`ram Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is Centerville Ma 02632 5/8/19
required for every
page. CitylTown 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
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
5/10/2019 Assessing As-Built Cards
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. Cityfrown 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: 10+
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:
Test hole data on file at BOH
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
Title 5 Official Inspection Form -
iia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 Valley Brook Rd
Property Address
Estate of Eleanor Braun
Owner Owner's Name
information is required for every Centerville Ma 02632 5/8/19
page. City/Town 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 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
DATE : 3/18/03
PROPERTY ADDRESS : 63- Valleybrook-Road
--Centerv_ille1Mass
02632
------------------------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1 000 gallon septic tank. RECEIVED2. 1 -Distribution box.
3. 1 -1000 gallon precast leaching pit.
Based on my inspection, I certify the following conditions: APR 2 7 2003
4 . This is a title five septic system. ( 78 Code) f§WH OF BARNSTABLE
5. The septic sytsem is in proper working order at HEALTH DEPT.
the present time.
6. Waste water is 5. 5 ' below the invert pipe of the
leaching pit.
SIGNATUR / .
Name : J . P , Macomber Jr .
Corripany ;,�oggPh per_M��4m��r 8_ Son, Inc ,
Address :__5Qx -U -------------
-_Q.e-nS2_YiL -e-,_ Ja--2Z.632-0066
Pnone : --508- 775_ 3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
IOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connectlons
P.0 Box 66 Centerville. MA 02632.0066
775.3338 775.6412
Y'
' COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM'
PART A
CERTIFICATION
Property Add ress:63 Valley Brook Road
Centerville,Mass
Owner's Name:Joseph Tweed
Owner's Address:1 41 B Searsvi l le Road
Smith Denni s f Mass n2660
Date of Inspection: 3/1 8/0 3
Name of Inspector: (please print)Joseph P.Macomber Jr.
Company Name: ,7_P_Macomber & Son INC.
Mailing Address: 134X 66
C'anf-arvi 1 IP ,Mass 02632
Telephone Number:gos-77r,-333R
CERTIFICATION STATEMENT
1 cenify 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
traiping 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
Needs Further Evaluation by the Local Approving Authority
_ Fails
Inspector's Signature: 4, Date:
The system inspector shall s mit 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I I ,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:63 Valley Brook Road
Centervi e,Mass.
Owner:
Date of Inspection: 3 1 8 03
Inspection Summary: Check A,ByC,D or E/ALWAYS complete all of Sectlon D
A. ystem Passe
/Il 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:
m is in proper working order
at t e resen i .
B. System Conditionally Passes:
tO 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 statemen explain. ts. If"not determined"please
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:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe($)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced -
obstruction is removed
distribution box is leveled or replaced
ND explain:
aThe 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:
2
f
Page 3 of I I
OFFICIAL INSPECTION FORM • NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropeM Address: 63 Valley Brook Road
rPflt-PYVI 1 1 e.,M.'ass _
Owoer:Joseph Tweed
Date of lospectioo: 3/1 A/03
C. Further Eyaluadoo is Required by the Board of Health:
., Conditions exist which require funher evaluation by the Board of Health in order to determine if the system ,
is (atlusg to protect public health, safety or-the environment.
I. S.stem ..ill pass unless Board of Health determines In accordance with 310 CMR 15,303(1)(b) that the
system is not functioning in a maooer wbich will protect public bealtb,safety and the envirooment:
AD Cesspool or privy is within 50 feet ore surface water
Cesspool or privy is witbin SO feet ore bordering vegetated wetland or a salt marsh
S%stem will fail unless the Board of Health (and Public Water Supplier, If any) determines that the
s,vstem is functioning in a manner that protects the public health, safety and environment:
.0 The system has a septic tank end soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
/9,0 The system has a septic tank and SAS and the SAS is within a Zone I ore public water supply
The system has a septic lank and SAS and the SAS is within 50 feet ore private water supply well.
The• � system has a septic tan); and SAS and the SAS is less than 100 feet but AP feet or more from a
private eater supple well' Method used to determine distance 1_7
This s\stem passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is Gee from pollution from that faciliry and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no otner
failure criteria are rrigeered. A copy of the analysis must be anaehed to this form.
). Other:
3
t }
Page 4 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:63 Valley Brook Road
Cent rvillefMasa_
Owner: ,Ie-Pnh `TWPPCI
Date of Inspection: 1.11�3/n3—
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N�
_ _ 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 t e distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool 1-4IMO
_ �equired
squid depth insssspeel is less than 6"below invert or available volume is less than ''A day flow
pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
/of times pumped
_ ✓ y portion of the SAS, cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
LlAny 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of.ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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— 1WPA)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 to 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.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:63 Valley Brook Road
Centerville,Mass.
Owner: ,7n-,Pph TWPPd
Date of Inspection: _3 fg/n
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
ZWere any of the system components pumped out in the previous two weeks
_ZHas 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 ?
ZWere 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,zAcluding 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:
Yes no /
,/ 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(3)(b)]
5
• y � T
Page 6 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:63 Valley Brook Road
C_enterville.Mass.
Owner: Joseph Tweed
Date of Inspection: 3/1 8/o 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):J-5 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: 02
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no):A)P [if yes separate inspection required]
Laundry system inspected(yes or no): Li 5
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)).20 01 -91 , 0 0 0 ga 11 o ns=2 4 9 . 3 2 GPD
Sump pump(yes or no): 2002-88, 000 gallons=241 . 1 0 GPD
Last date of occupancy:S41,9dM Sprinkler system is present.
COMM ERCIAL/INDUSTRIAL
Type of establishment: ItO
Design flow(based on 310 CMR 15.203): wd
Basis of design flow(seats/persons/sqft,etc.): 0/-
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):/, Q2
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records /%
Source of information: J��7� �!��� 1 �/ j�
Was system pumped as part of the inspection(yes or no):,&�!
If yes, volume pumped:_gallons-- How was quantity pumped determined? X4
Reason for pumping: ,f A
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
44 Shared system(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe): 111J0
Approximate age of all components, date installed (if known)and source of information:
�(Q
Were sewage odors detected when arriving at the site(yes or no): 4*6
6
Page-7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 63 Valley Brook Road
Centerville,Mass.
Owner: Joseph Tweed
Date of Inspection: 3/1 8/O 3
BUILDING SEWER(locate on site plan)
Depth below grade: 00 4" Sch. 35 PVC pipe
Materials of construction: dzocast iron AV40 PVC other(explain):and fittings.
Distance from private water supply well or suction line: Id It
Comments(on condition of joints,venting, evidence of leakage, etc.):
Joints appear tiaht.No evidence of leakage The system is
vented through the house vents.
SEPTIC TANK: y' (locate on site plan)
Depth below grade:
u
Material of construction:� ,, oncrete ,petal, I.fiberglass4, polyethylene
/ll6 other(explain)
If tank is metal list age:, , Is age confirmed by a Certificate of Compliance(yes or no):&t�(attach a copy of
certificate) l L
Dimensions:
Sludge depth: 0'"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: y_� I �i
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: ,d'�,,d
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Pump septir tank every 2-3 yp-ars- Tnlet & outlet tQes are
in pl ar-a Tha rank i G ctriirtura 1 1 )z sound and Shaw-, nn
evidence of leakage.The liquid level at the outlet invert
A>_ 51 "
G EASE TRAP (locate on site plan)
Depth below grade: .(J.A
Material of construction:,(Mconcrete W metal W fiberglass polyethylene 0 other
(explain):_ JA
Dimensions: _"�J4_
Scum thickness: t_
Distance from top of scum to top of outlet tee or baffle: A14
Distance from bottom of scum to bottom of outlet tee or baffle: ,d1�
Date of last pumping: AVA
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
( _r_P;4ge trap is not present
7
•
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:63 Val y Brook Road
rentPrvil 11 ,Ma_cc,
Owner: Joseph Tweed
Date of Inspection: 11
TIGHT or HOLDING TANK i6e6. (tank must be pumped at time of inspect ion)()ocate on site plan)
Depth below grade: A)I!
Material of construction: concrete metal ,�14 fiberglass.&lr9 Polyethylene�other(explain):
.4
Dimensions:
Capacity: gallons
Design Flow: allons/day
Alarm present(yes or no):
Alarm level: /✓4 Alarm in working order(yes or no):
Date of last pumping: iyn
Comments(condition of alarm and float switches,etc.):
Tight or hol cl; ng tanks are not present
DISTRIBUTION BOX: d (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
AD—
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.):
Distrihutinn hny ha-, nnP 1 atPral Na ev; dence of c;01 ; dS arry over,
Bot ; c ci-riirri a1 1y _snuuld anr9 sbnws_ncLP y; rlpnr,e of 1 PakagP
into or out of the box.
PUMP CHAMBER4"(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and.appurtenances,etc.):
Piirnp chamb r is not present
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 63 Valley Brook Road
Centerville,Mass.
Owner:Jn--,Pnh TWAPd
Date of Inspection:3 f 1 R O R
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
—TIP-1 000
If SAS not located explain why:
.ocated: See page 10
Type
leaching pits.number:
&9leaching chambers, number: O
leaching galleries,number: 0
Vf1 leaching trenches,number, length: O
leaching fields, number, dimensions: O
T-overflow cesspool, number: Z
/ innovative/altemative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
nd to medium fine sand.No signs of hydraulic failure
nr nnnrl . ncY gin; is are dry Vegetation is normai.
CESSPOOL &1 (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: AIA
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
not present.
PRIYy4 (locate on site plan)
Materials of construction:
Dimensions: ,f,v
Depth of solids: I
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Pr; vv is not present
9
• w�
Page 10 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress:63 Valley Brook Road.
Centerville,Mass.
Owner:Joseph Tweed
Date of Inspection: -if 18/o 3
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.
�9i
i
_ — (o 3 Vo,I c,y book �d
10
f,
Pagq 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:63 Valley Brook Road
Genterville,Mass.
Owner: Joseph Tweed
Date of Inspection: i/1 R/0'1
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
i
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: NA
YESObserved site(abutting property/observation hole within 150 feet of SAS)
E_Q_Checked with local Board of Health-explain: NA
YESChecked with local excavators, installers-(attach documentation)
yp.SAccessed USGS database-explain:httA: //town,barns table.ma.us.
You must describe how you established the high ground water elevation:
Used: Gahrety 9 Miller Mod l- 1 /16/94 Ground water elevations above sea level.
Used: USES- bhsprvatinn well data, the 1992
Used: USES- Tpchnical ht,llPtin 92-000-1 Plate #2 Annual_h ranges of ground water
4Z1P17a";croup
i ncu 7 n teary-1��2
Leaching
Pit ;eet
I
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is 6!)
feet.
I
11
1 r M •,
y r.n r•r.-nrT--�-irn:are.•nsen�-�.rtr.nr.rrrt�.++.•n�rmn.+nn nrrav�'�rrnn•+ .err+-r-r.�-.
TOWN OF Barnstable BOARD OF IIEALTII
SUI;SURFAU SF.HAGF DISPOSAL SYSTEM INSPECTION FORM - PART D - CEKTI FICATIUN I1
•••T••t•T••.••.•.—T.111�.�TT1�'IITI'R.Tl11�T/RTT/A►'TT1'r�5.1 r'ItTT7iTT�T�RRAf�1�Ttfwr7 Tn •r..rrr•r--.• .-. A
-TYPE OR PRINT CI.EARLY-
PI?OPERTY INSPECTED
STREET ADDRES$ 63 Valley 'Brook Road Centerville,Mass. '
ASSESSORS MAP, BLOCK AND PARCEL # 188-160
OWNER' s NAME Joseph Twded
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J P Macomber & Son Ind-.`
COMPANY ADDRESSBox 66 Centerville Mass. 02632
Street Tvvn or City Stag tIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED ;
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
r
The inspection which I have con acted has found that the system fails to
Protect the public health and the environment in accordance with Title
6 , 3.10 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
/_/
Inspector Signature Date
copy of this certification must be provided to the OWNER, the BUYER
Dnd
where applicable ) and the I30ARD OF HEALT'JI,
* If the inspection FAILED, the owner or" 'Perator shall upgrade ' the eyetem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 16 , 306 .
partd . doc
TOWN OF BARNSTABLE
"3 Valley Brook Road SEWAGE #
LAGE Centerville,M.ass. ASSESSOR'S MAP & LOT 1 88-1 60
'INS, _ LER'S NAME & PHONE NO. _J_P.Macomber Jr_
SEPTIC TANK CAPACITY 1 000 gallons p1 L-, box-
LEACHING FACILITY: (type) 1 —LP-1 000 (size) 1500 gallons.
NO. OF BEDROOMS 3
BUILDER OR OWNER Joseph Tweed. ( inspection)
PERMIT DATE: COMPLIANCE DATE: -4 /1 A /nl
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of!caching facility) Feet
Edge of Wetland an) LeacN g Facility(If any wetlands exist
within 300 fcet f Ieachi,�g E"cili
Feet
Furnished by
1, t
r -�9i
. 3
(� 3 V0,11ol bn'ook- rd
O CAT IO� PERMIT NO.0T SEWAGE
If 00
VILLAGE
I N S T A LLER'S NAME- i ADDRESS
BUILDER OR WNER
t-
DA T E PERMIT ISS-IY E D_
DATE COMPLIA-NCE VS-SUEDE
i
5b
q,? <, s No...._.. -
�� .. F .. ...................
.. . ;. xs
THE COMMONWEALTH OF MASSACHUSETTS
0 BOAR® OF HEALTH
\� ........��.VJ.d�.............OF.......:..... rn..... .......................
Appfiration for Di-spog al Warkii, Cnomitrurtion Fermi#
Application is hereby made for a pPermit to Construct (✓f or Repair ( ) an Individual Sewage Disposal
............................*......V�.................................
Locatio -,Address
.nrrn ............... ........................................... -------- �.O.A. -......--...----•--•-------................
o Owner
Installer Address Type of Building Size Lot__V5.0.%_S._..Sq. feet
Dwelling—No. of Bedrooms......................................_.....Expansion Attic Garbage Grinder 419
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ---_-----_---------------•• .
W Design Flow...............VV0..................gallons per person per day. Total daily flow............._73----�--o------_......gallons.
WSeptic Tank—Liquid capacitvN grallons Length---------------- Width................ Diameter________-___-__ Depth................
x Disposal Trench—No..................... Vidth.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet..._................ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing t }
'-' Percolation Test Results Performed by...__.__ t" ... '_..1" .-"...__.. ......��-.......
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...................
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------------------------------------------------------- ---- ---- .........................................................
O Description of Soil '' -a-��-•-------------- ................�v a --------------- .............
U .......................................!�=-'-�.--•---•--......_CO.WL4.-c.............5.-Qt^-- -- - igC%k U V
-------------------------- �n.\_a'-..._.........•..me A------------------- Q^ . -------------------......--------------------------------------
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 iIIL LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed----� ----U-..---- --------------- ' a T—�
Date
Application Approved By..............._ ."A..`��...__.............. jf!P.�.Yf2L-----------.
Date
Application Disapproved for the following reasons:------••••-----------------•----••-----.....-----•••-•------••--••----••----------•••-•--•--•-•---•-•-••------•.
------------------•-----------••------•-......-•--••----•-•--------------••-••--••••---------•---•-•--••-...----------•----•---•---------•----•--•----------•••--•---•---••-----....----•--•-•---------•-
Date
PermitNo......................................................... Issued-.......................................................
Date
Fus...13,...............
=i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..
7 . .............OF..............
.................................................................
Appliration for 0hipmal Workg Tomitrurtiun rumit
Application is hereby made for a Permit to Construct (...>j or Repair ( ) an Individual Sewage Disposal
System\at: \ \
•• �!•��` ........ �?. �! ........�:�..... �?� '..'.�...`.�.... ------------- ....... ..-------•--......--••----------•..
J C .. Location Address I �; { j r t No.
!-1.:.l ..¢'^.............................�..\........................ .........�eac<'_-\d__. __.......... ........i............•............................
W �_i- .0 ......�.,O Owner---.. .....---� ..�.....-- ---�......s�..._.
Installer PQ Address
14 Type of Building Size Lot..���..Q-----.---Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (\)Q Garbage Grinder (P y
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ---------------------------------------------•-----------------------------------•-----....---------------•--: ----------............__..
Design Flow---------------- - ------ : .(
W g gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity\ v.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... 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 ( ) b
Percolation Test Results Performed by............ .�......_.V'A...............��,'�__"...... Date_._.�.:L_�----------------------------
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........................
P+' ----------- --- -------- ---- `
D Description of Soil ` ...............�-`. ems.r --------•---.....�------------ !}l-' i =
"� ,
------------------- -------------------- s�' ` cy e. c 5 CA r. CJ
------- -------------------------------_-- - �-----------•------------------------------------------------.----------
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 TITti' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.....)( - --
----------•-----•--- ------------•---------
f1 Date
Application Approved By............... =x�' ... . ......................--------- --•--- '.Z `1.. t•------------
Date
Application Disapproved for the following reasons---------------••----•------•--------------------....---------•----------------------...........................
---------------------------------•---------------------------........._.._.
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. .................. . ..........
(9rdifiratr aaf Taantplinnrr
THIS IS TO. CERTIFY, ,That the Individual Sewage Disposal System constructed (✓� or Repaired ( )
Installer - LJ i
-. .... -- ------
at_ ^; ..... n 4
has been installed in accordance with the provisions of TITLE ofThe State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................7................... dated----._.....-------------------..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS 'CsU NTEE THAT THE
SYSTEM WILA F DICTION SATISFACTORY.
/� V'- .......••....................••-•....--•--•.._.. Inspector
,. DATE..............Y`�.....-•--••--- P •�------------------._.....----------------•---•------•-•----•-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Noc�a'? :> n OF.. k`'7Cf.. �, (�...... ..:�................. FEE.._.....................
...
�i��raaa�nl nrk� �nn�,�ruan rrnti�
Permission is hereby granted__._. .. ��'S.�. _�_....._---=..` a
............
to to Construct or Repair ( ) n I.ndividual Sewage Disposal System
at No.......A''=-`=--.'SZ........... ----------• L �'1 + .�<, ------------
Street
as shown on the application for Disposal Works Construction Permit No.....................j�Dated..........................................
,.�-• . ..I .. . .Health-----
of
DATE._--••--�--`-�----.�.!...t�.fp.'a.._.-.................-..........
Board
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
' A
S�►.rG�.L-. FaM��Y - � BE�RQoM
!, i.1D G�.RBAGE .(�t2.I1JDER. ,
I� DA►L.Y FLOW z 110 Y►° 3 x �a3oG.Pv.
II SEPTIG TA►.JK = a3oxl5o% =.4956Y0.
u5�• 100o GAL.
P vo0 GAL. v<< �pT�
015PoSAt_ IT u5E t
5�DG.WALt_ A2GA• = t 5o S.F So 1 �°�3
375 G.Pq
BOTTOM ARF-A: . Inc SiF
So S.F x ►.o �i•o
'7oTA1.. �FiStC.IJs .¢25 G.PD. 1 1 �
•TOTAL DA I Ly FL-OV4 = 330 G•PO, 4- 1'
PE2COI-ATION RATES V'IN VAIN 55
6y p
oe frN
4�' I
R"iARD$�G � ALA I I 148 t70
A. �1 a W.
-SAXTER
,Nm 24048G 2 O �N
7 a
G�
8U 10ALE~
• I
TEST (?1220 f �[�s�ta TOP Fup=66'3:�
(o �
5L% 33j INv. 35,0
LVAAA ►oou INv•
5%OKo 9nX INS. SrPTI� 34'g
Z t o0o INY• 3"
GA►.. 32 0 `
1_EAcu ;
GoA•ruu PIT .. INY.. INY. . . i
wl WIT14 32.2 32
WASUGD
8 670 Her
• fJI•� I
74AD G E R.T I F t G D P L o'T
i.
PROFILE l.oC4'�IotJ cI� �,
-74 f2� wo 5CA.LE `jEAt,6 ` (io' VATS "l •14.07-
0 WATE7.
P�-P,N REF 6 Q'EN GE
CEQT1FY THAT THE vIJbATIOW 15'Ac)WN !
NE.RC.o►.1 COMPL` !S YJ►TN•T NE S I DI;LIN E
AW0 SL-r15AC. R.6QVIR 9;tASW'I oF -Tµr-_ , L,ev,r 13
-Ta W N O 3+QP-1�5'ta��$ AND 1 S
LOCATED W►T IJ NE FL•00D PLAIN c...ov12T �55 �
DATE '14 • BAXTEize NYE INC•
REG I S"t EQ6r'D'I.,A►J D S v�v E�oZS i,
Tuls PL.o.N t�i NOT BASt=t� oa AN os•rtz.vlt_LE - �KAsS•
.Iu5TRutAeW " 5u2vGY j�'TNE orP51=T5 6u6utj)
yra•r g
APP
���.DTd C�CTr Y-.MI�C l_c�T L.ItiIE�� L.!