HomeMy WebLinkAbout0110 JAMES OTIS ROAD - Health 110 JAMES OTIS ROAD, CENTERVILLE
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UPC 12534
No.2 qs
HASTINGS,MN
v
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 110 James Otis Road RECEIVED
Centerville, MA 02632
Owner's Name: Owen Kilcommins AUG 3 0 2001
Owner's Address: Same
TO
()F BARNS I ABLE
Date of Inspection: August 27, 2001
�HEALTH DEPT.
Name of Inspector: (Please Print) James M. Ford
Company Name. James M. Ford
Mailing Address:'. ` ' "" P.`O:Box 49 s Map: 170
Osterville,MA 02655-0049 Parcel. 153
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
J 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
Conditio ally Passes
Needsurter Evaluation by the Local Approving Authority
Fails
t
Inspector's Signature: 14 Date: August 27, 2001
The system inspector shall subm�copyyf 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 describesconditions.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 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION" (continued)
Property Address: 110 James Otis Road
Centerville. MA
Owner: Owen Kilcommins
Date of Inspection: August 27, 2001
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:
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 replacerrient'or'repair;as approved by the Board of Health,will pass.
t
Answer yes,no or not determined(Y,N,ND)in the for the following statements. 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(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times-a year due to-.broken or obstructed pipe(s). The system will
(with approval of the Board of Health),: ___
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 110 James Otis Road___._ __ _,___ _,�}�.____ ��� �,' .. •_• n��'i
Centerville, MA
Owner: Owen Kilcommins
Date of Inspection: August 27, 2001
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.ofHealth(an&Public Water S.upplier,jf 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 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.
3. Other:
3
Page 4 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 110 James Otis Road
Centerville. MA __..' _ ' ;k,. !''3 `• _ t
Owner: Owen Kilcommins
Date of Inspection: Augaust 27, 2001
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 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'i00 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,forrcoliform 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.]
No (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 System:
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-IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM
PART B
•.CHECKLIST
Property Address: 110 James Otis Road ,, 4 • ,. b=, : ;f,,,.
Centerville. MA
Owner: Owen Kilcommins ,s •:.;s', "_ _..
Date of Inspection: August 27, 2001
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.;?.,
✓' =� r ;Was the site,in for signs of break out?
w. ,� ✓. - 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:
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
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
_ SYSTEIVI=INFORMATION
Property Address: 110 James Otis Road —
Centerville. MA
Owner: Owen Kilcommins
Date of Inspection: August 27. 2001
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage syste►n(yes or no): No rif yes separate inspection required]
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2000-99,000 gals.; 1999- 108,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR-15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
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: Pumped in 1999-per ownerN
Was system pumped as part of the inspection(yes or no): 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 ofthe current operation and maintenance contract(to be
obtained from system owner) t
Tight Tank Attach a copy of the DEP approval
• �'.( 4
Other(describe): _ ., _ i. Y ;_
- Approximate age of all components,date installed(if known)and source of information: -
Feb 26185-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
`SEWAGE PART C
e_'SYST.M�INFORMATION (continued)
Property Address: 110 James Otis Road
Centerville. MA
Owner: Owen Kilcommins
Date of Inspection: August 27, 2001
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron ✓ 40 PVC _other(explain):
Distance from private water supply well or.suction line:
Comments(on condition of joints,venting,'evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 16"
Material of construction: ✓ concrete metal —fiberglass —polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes of}no) (attach a,c0py'of
certificate) :
Dimensions: 1000 gal.
Sludge depth: 1" -
�.
Distance from top of sludge to bottom of outlet tee or battle: `" 30"`
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 9 ._ . - -
Distance from bottom of scum to bottom of outlet tee or battle: 13"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
The tees were present The liquid level was even with the outlet invert There were no signs of leakage. Scum and sludge were
minimal
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,"structural integrity,liquid levels
as related to outlet invert,evidence of leakage;etc.):
7
5r. , < �..••„,:,.�� ,�,.�-ram ,�,�.,,,
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION'(continued)
Property Address: 110 James Otis Road
Centerville, MA _..
Owner: Owen Kilcommins
Date of Inspection: August 27, 2001
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
-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.):
The D box was located but not dug up There were no signs of failure in the leach nit
PUMP CHAMBER: None (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.):
t
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,).,r=3%r,�=:.;SY.STEM'.INFORMATION(continued)
Property Address: 110 James Otis Road
Centerville, MA
Owner: Owen Kilcommins
Date of Inspection: August 27, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
T -
YPe
✓ leaching pits,number: 6'x 6'with 2'stone(per design plans)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
_ ...' .. _overflow cesspool,number:
w_._... ... . ........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.):
The pit had Y ofwater on the boitoA The scum line.was at the same level,-,There were no signs offailure.> The bottom to grade
was approximately 8' The cover was 2'below grade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION'(continued)
Property Address: 110 James Otis Road.
Centerville, MA
Owner: Owen Kilcommins
Date of Inspection: August 27, 2001
Map: 170
Parcel. 153
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.
g,ac,l�
A '
a '
Al - a5
440
A3- 33
33- yy
Aq - Yy o
3y- y 5 Y
10
Page 11 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
f SYSTEM INFORMATION,(continued)
Property Address: 110 James Otis Road
Centerville. AM
Owner: Owen Kilcommins
Date of Inspection: August 27 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25' feet (Adjusted High Ground Water Level is 22.6)
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain:topographic&water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: ,
The bottom of the leach pit to grade was approximately 8' Usini the Barnstable topographic map aril the Cape Cod
Commission water contours map the maps were showing approximately 25'+/-to ground water at this site. Using the Cape Cod
Commission Technical Bulletin the high ground water adjustment for this site(SDW 252 Zone A 7/01)was 2.4'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report.
11
Alk G•a��1W4r, l vl
A
S Dw aSa. 6 -7k
— Lcv I
DATE: 7/16/96
PROPERTY ADDRESS: 11 (1 .TAmaa pti a Rciad R �' ®,
Centerville ,Mass . AU 1 1996
HEALTH DI_PT.
0 2 63 2 TOWN OF BARNSTABLE
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 ,gallon septic tank.
2. 1-Distribution box.
3. 1 -1000 gallon precast leaching pit.
Based on my ing:lection, I certify the following conditions:
1 . This is a . title five septic system. ( 78 Code )
2. The septic system is in proper working
order at the present time.
SIGNATURE:
Name: J . P .Macomber
Com an J P . MacoMber & Son Inc .. ,
Address:_-B-e-x-,6b------I-------
Cente�rvi1Le LMass_-02632
Phone:-__5Q875 3338--------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACO�RBER & SON, INC.
Tanks-Cesspoola-Leachf fields
Pumped L Installed
Town Sewer Connections
P.O, Box 66 ' Centerville, MA 02632-0066
775-3338 775-6412
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
WU F.Weld
Q emot Trudy Cox*
8--tally
Paul Glluccl David B.Struhs
LL cio,remor CornrrJaiorrr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropertyAddreaa: 110 James Otis Road Centerville,MapjdrewofOwner.
Date of Inspection:7/16/9 6 (If different)
Name of lnspeotor.Joseph P. Macomber Jr.
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338
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-site sewage disposal systems. The system:
asses
-Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspeetorra Signature: / ���A/Ga , Date:
The System Inspector submit a copy of this ins}*ction 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=d copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B. C,or D:
A) SYSTEM PASSES:
_ 1 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.
Bi SYSTEM CONDITIONALLY PASSES:
Vt.) One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,paaaes
inspection.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not•determinee,explain why not)
The septic tank is metal,cra^.ked,atructuraily unsound,shows substantial infiltration or exilltration,-or tank failure is
imminent• The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 a FAX(617)5WID49 • Telephone(617)292•SSW
��Prinled on R"Ied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART A
CERTIFICATION (oontinued)
110 James Otis Road Centerville,Mass.
0%".:*r. Abraham Haddad
DA(e o! .7/16/96
Bl SYSTEM CO;.'DITI0NALLY PASSES (continued)
�® Sewage backup or breakout or high static water level observed in the distribution boat is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four tunes 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) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
—A-0 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.
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•
v0 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.
Z) 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.
did The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well.
A0 v— •,—.Lu has a septic to ik 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 coliform bacteria and volatile organic compounds indicates that the well is free
.ciou from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddreas: 110 James Otis Road Centerville,Mass .
Owner. Abraham Haddad
Date of Inspection: 7/1 6/9 6 '
D1 SYSTEM FAILS:
•
BO I have determined that the system violates one or more of the following failure criteria as defined in 310 CMIi 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure. _
it 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 C"e ground or surface waters due to an overloaded or clogged SAS or
cesspool. e
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
UA4k P
7-
ND Liquid depth in eesepeoi is less than 6"below invert or available volume is less than I/2 day flow.
• d� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
j1 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
LD 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 60 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
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
AIP The 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
health 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 supple'
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for fluther information..
(revised 11/03/95) $
SUBSURFACL 61"*vVA(;L DISPOSAL SYSTEM INSPECTION FORM
PART B
CUECKLIST
PropertyAddr"&- 110 James Otis Road Centerville,Mass .
Owner. Abraham Haddad
Date of Inspection: 7/16/96
Check if the following L.-.-v L_�u done:
was rv.iu"Lcd vi ,h ,wiwr, uccupant,7and Board of Health.
have L>en pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large VOIU140S Of wuLer have not been introduced into the system recently or as part of this inspection.
built plans have been obtaizwd and Note if they are not available with NIA.
_T- facility or dwelling was inspectod for signs of sewage back-up.
Zhe kvgten, dr-c-p not receive non-&uiiuu-y or industr
ial waste flow
.4z"The pity 4np rp trd for siip-a of bma4%uut.
ZA11y tem components,t9cluding the Sc:? ':',L,4;orption System, have been located on the site.
All
septic tank manholes were Luicoverud, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, diinwisioiis, depth of Liquid, depth of sludge, depth of scum.
Zsix a and location of the Soil Absorption System on the site has boon determined based on existing information or
�.imteda by non-intrujive methods.
ci]ity ner (.inJ cfciinants, if LlIffevviit from owner) were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95).
"?FACE S17WAGE DISPOSAL SYSTEM INSPECTION
PART C
SYSTEM INFORMATION
r 110 James Otis Road Centerville,Mass. '
Abraham Haddad
FLOW CONDITIONS
RESIDEN'TIAI:
Design flow: K ous)0VY'A0y o
Number of bodroonu: 3
Number of current rwidents:_9 A*wfz
Garbage grinder(yes or no):21D
Laundry oonnected to system(yw or no): S'
Seasonal use (yos or no):_YIS.S �..
Water meter road nV, if available: 1 C!j' !b ! 6DD ��1 5 e . 2
�- y
Last data of occupancy: —ho/
C_O MM ERC IAL/I NDUSTRIAI:
Type of establidhmeat:___d/ .._.....__...
Dwign IIow:-4 L,4-9ullotu/1,ty
Grease trap present: (yuJ or no)A9
Industrial Waste Holding Tank present: (yes or no)&&
Non sanitary wr.:afr• !:-1- Title 5 system: (yes or no)1��'
Vi,4Lcr meter
Lout data of ra-u;arcv:
"t d„tc
GENERAL INFORMATION
PUMPING Rz*X'.-: no f into ustion:
Systou: �Li ;vi:i of inspection: (yec or no)"
ons
1'YI'E F SY3112..'
al>4orpt:on Yjitem
PL
)44, attach previous inspection records, if any)
.1I'PRO\lSi ,:.;.. -,�r, d,:te installed (itlntown) and source of information: _
`#a
Sewage odors dotoct,,,d when arriving at the site: (yes o1ro) A?�
(revised 11/03/95) 6
SECTION - SEWAGE r
12 -SEPTIC TANK-
-"D"BOX - -LEACH
OF- WASHED MSL1� "2"OF INTO Vi"
TOP
r?-1. WASHED STONE..:
• 1
IN• OUT IN• OUT IN•SEPTIC
,
Cv TANK
F ivC� 'IG E V. / r ELEV. .
' ELEV. EL V.
ELEV. ELE�. -!'a.I�
.WASHED STONE
.. 60ZC� I /• ��,r, 44 I f3o
TEST HOLE LOG P
' �� ''• ' BEDROOM HOUSE. .
TEST BY r WITNESS DESIGN ,
TEST DATE (9 5 `
T.H. • 2
ELEV.rj'f E DISPOSER OISPOSER
RC RATE '�2 rAINAN.
,del SE TANK 3 O
c v R Q'D SEPTIC TANK SIZE .... .
LEACH F ILITY
377i O G/D, ..
SO SIDE 8 ( 0 G/D.
GO BOTTOMT AL
S
USE: LEACHING
s B D M, to IF, D7"TN-
WATER ENCOUNTERED
i
NOTES; (6LESS OTHER SE NOTED) L
TAKEN FAOM �' A I1i I OUADRANG E MAP
1,DATUM(MSI)— _____,_,AVAILABLE �
2.MUNICIPAL WATER 1 _ •`4
3.PIPE PITCH'YA,4
PER'FOOT.
4.DESIGN LOADING FOR AL PRE-CAST UNITSt AASHO' t AWt
S.MIN.GROUND COVER OV R ALL SEWAGE FACILITIES:(1)FT.
6.PIPE JOINTS SHALL BE DE WATER TIGHT TO BE ACCORDANCE WITH COMM.OF MASS.
7.CONSTRUCTION DETA►.
STATE ENVIRON L CODE TITLE S `� 0 741o�Ja.0
MENT
UD•.. REG.PR EER
BOARD OF HEALTH
(PROPOSED)-o-o-O-o- APPROVED
DATE----
CONTOURS �p�1-I�JTAP�I.rG MA
• r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C. -
SYSTEM INFORMATION (continued) '
opertyAddress: 110 James Otis Road Centerville,Mass . '
wner: Abraham Haddad
ate of Inspection: 7/16/96
PTIC TANK:_&00 g,�40� *—AAe
sate on site plan)
epth below grade:._
aterial of construction: concrete _metal _FRP —other(explain) •a,
imensions: ' t
udge depth: h4
istance from topof sludge to bottom of outlet tee or baffle: 4-c e—
um thickness:-f�� -e—
istance from top of scum to top of outlet tee or baffle:T/�E�
istance frorn bottom of scum to bottom of outlet tee or baffle.�9f�
mments:
commendation for pumping, condition of inlet and qutlet tees or baffle• depth of liquid level in relation to outlet invert, structural
�rity, evidence of leakage1. , etc.) P_ulgP�,jn— f� every 2-3 �aa.ra�Tnl at & nntl at -i.a _
• tt .
REASE TRAP. /?JD4Ae,
)cafe on site plan)
pth below grade:;
aterial of constrq�ion�jQ:oncrete _metal _FRP _other(explain)
mensions•
um thickness:_
stance from top w't scum to top of outlet tee or bahle:.AJ)L
stance from bottom of from in bonnm of outlet tee or 6111e:AQ
mments:
commendation for pumping, condi-n,of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
egrity, evidence of leakage, ett.t_
0
wised 8115195) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C C,
110 James Otis Road Centervi11e,Mass .
uw4_.. Abraham Haddad
D.W L 7/16/96
T1 01.i:
(locuta ou •
Depth below gMde:_.j '
Material of oonstruction:.(e&ac:vte_metal_FRP_other(explain)
— - A.)A
AIV
Dimensions: AIA
Capacity:_4 4 gallons
Design flow:_ &R gaAoWday
Alarm level: 444
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX,_
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if avel and distiibut'o u equal, evidence of solids carryover,evidence of leakage into or out of box,etc.)
1J—Dox is e�en1;, p „Y.� 9 f solids carry over;No evidence o —leakage
into or outo e -d s r u ion box.
PUMP CHAMBER:.L�"L.
(locate on site plan)
Pumps in working order:(yes or no) !!1/4"
Comments:
(note condition of pump chamber;condition of pumps and appurtenances,etc.)
Al, �.s�,�1P�7►S
(revised 11/03/95) 7
PART C
INFORMATION (oontinued) lQ�
Property Address: 110 James Otis Road
Owner-. Abraham Haddad
Data of Inspeotiow7/16/96 Q
SOIL ABSORPTION SYSTEM (SAS):�LoD 941.& Q� �J>v, Aran ) ,,CA /q
(locate on site plan, if posaible; excavation not requires, but uuiy be approximated by non-intrusive methods)
If not determined to be present, explain:
r
'ryPe: �
leaching pits, number:
leaching chambers, number
leaching galleries, number:
leaching trenches, number,length: A
leaching fields, number, dime ens: _...__..
overflow cesspool, number:M1 —
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
ROJIS AAA page 5A ;No -gigns of hydgaulic, -failure or Donding;A vege -a ion
CESSPOOLS:•�OyA2
(locate on site plan)
Number and configuration: -'yi9
Depth-top of liquid to inlet invert: A)4
Depth of solids layer:
Depth of scum layer: ti
Dimensions of cesspool:_ NA
Materials of construction: A114 _
Indication of groundwater: V
inflow(cesspool must be pumped as part of inspection) AyA
Comments: (note oondition of soil, signs of hydraulic fuJure, level of ponding, condition of vegetation, etc.)
66
PRIVY:'V't'VQi
(locate on site plan)
Materials of construction: AA Dimensions:- .Vo#
Depth of solids: Jll/Q
'Comments: (note oondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
(revised 11/03/95) g
S UI3".URFACE SEWAGE DISPOSAL SYSTEM INSPECTION •FORM
PART H
SYSTEM INFORMATION continued
SKETCH OF SEWACF C :SPOSAL SYSTEM:
include ties to zL least two permanent references landmarks. or benchmarks
locate all wells within 100 '
Centerville Osterville Marstons Mills
Water Company
428-6691
Jr 1, yN \ L
I
DEPTH TO GROUNDWATER
_.. deptn t o grouq4y to -R�1�5' 0 T s' X CZ'-
r+akthod of determinz$ion orsapproximat ion: See page 5A No water encountered
.,,_at 1 .:WYien sy-stem wa.a .i.nstallgd-°in 1985 .'
c. z
tW �
Ln
S�'l1f 3r�1
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ' 'ion of Water Pollution Control .
+•msnrn rrs rts�-rT^asr►raen+nt+n►vnns•eTrrrnivs'+t+tnri�.rr.�m nsrey ns7nein•n No= Tfr*.rr^.trrm*`.'.sa.r••}
'PORN OF Barnstable WARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
`/ h•••rth^r•••;.r—n..r.^.srn:nr.+..•n..+r.rnrms'.r.+r-ens're•.•.vsnrrarnmr-�+r�aserwe+amn�•.�rro�s s..nn v+•+rrr•*r•�r•�s.�
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
rr
STREET ADDRESS lin Tame o+gs ,,,d Centerville.Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Abraham Haddad
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr. .
COMPANY NAME J.P.Macomber & Soif 'Inc.
COMPANY ADDRESS Box 661- Centerville,Mass . 02632•
Street Tort, or City State LIP
COMPANY TELEPHONE ( ) -
508�,�75 8 FAX � 508 790 1578
1Z9 R�.Oar.T.T1RR�i�T�'�3f.m90O �TC�
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
complete 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 ,
• n i tli+lt,
Check one:
XXXXXX=XSysteui 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*
The inspection which I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
6 , 310 CMR 15 . 30.3, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
u 1 y^•
01,
Inspector Signature i Date 7/1'8/96
---,,, One copy of this ification must be provided to the OWNER, the BUYER
( where applicable) and the DOARD OF HEALTH.
* If the inspection FAILED, the owner or""operator shall upgrade ' the system.
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3,10 CMR 15 . 305 . '
partd.doc
TOWN OF BARNSTABLE
LOC.ATION' //0 ®Z!S AAA
VILLAGE &nAWiliU6 YY9)4 5 S ASSESSOR'S MAP & LOT
AME&PHONE NO.' � f /� � •
SEPTIC TANK CAPACITY >O�v
LEACHING FACILITY: (type) 1 IXl? e� (size) /�
NO.OF BEDROOMS j�
MMMWUR-OWNER ��l�'AdM �Ir9l�lr<l/Q
DATE: ->� �.� COMPLIANCE DATE: 7-4
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) V Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet f leaching ci ' ) Feet
Furnished by sm..Ja
O T i S R �
TOWN OF BARNSTABLE
LOCATION 10 JArms �-S R-�• SEWAGE #
VILLAGE pv► erV1 ASSESSOR'S MAP & LOT O /S
INSTALLER'S NAME&PHONE_ NO.
SEPTIC TANK CAPACITY out, (SAI.
lo
LEACHING FACILITY: (type) IT &X& (size)
NO. OF BEDROOMS
jam,•
BUILDER OR OWNER Ol. C,^ (�► I COMMt�S
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
h 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 6flleaching facility) Feet
Furnished by .Sr��;�
C1
a,- iio
a O fia- aq
33
Ai- q
O l3y- Yam.
L0CA ION ( SEWAGE PERMIT NO.
G o
VILLAGE
(n�O..c�.u. ✓
`If�INS LLER'S NAME & ADDR jSS
ly,
e U I L D E R OR OWNER
ca
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED J
o ,-
G I �
ay �'
073
LOCATIOL,441�11( SEWAGE PERMIT NO.
669
9 .r3 r
'VILLAGE
INSTALLER'S NAME&ADDRESS
/2. mze,�
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
31 �f--
O