HomeMy WebLinkAbout0082 LAKESIDE DRIVE EAST - Health (2) 82 Lakeside Drive East
Centerville
A = 252 1004
r;
' LA
2, 5yi 3q' O
�47' 3�`
TOWN OF BARNSTABLE
f,)CATION Z?Zakax,we- Oe/Ua-- -6,4s)' SEWAGE#
1LLAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. CV)d 30<,31SU
M SEPTIC TANK CAPACITY /o®o 6joLiolU
LEACHING FACILITY:(type) 3 ROWS 'Y ,Oer#'O PSG(size) 'X 4/0
NO.OF BEDROOMS
OWNER %7®i/V dLPA-,,Vfi®C,-- ZV7
PERMIT DATE: COMPLIANCE DATE: ri CIA
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 leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
�q;�_
j
I-- i +
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
pplicatton for �Btq;poal �&pztem Con0trurttou Permit
Application for a Permit to Construct( ) Repair 06 Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No.-77�v L 71 -5 Owner's(Name,Add ss,and Tel.No.Z �ry �� �
Assessor's Map/Parcel `Z SZ, 'Pot S Ce lo' j
DW1r+
Installer's Name,Address,and T I. o. Pe �^ Designer's Name,A dress d Tel. o.
LOAD.,( -No ���o* kk Nl4, 0-10q,1 939AJN,wshe lMO"X�11+ ,ysYl
Type of Building:
Dwelling No.of Bedrooms S Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
i
Other Fixtures
i
Design Flow(min.required) gpd Design flow provided 7j�7� gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank I Qj2 0 QA If di i( Type of S.A.S.
Description of Soil
Nature of Re airs.orA.,lte.ra,tions(Answer hen a plicable 2 tS OL 047OX
Date last inspected:
Agreement:
The undersigned agrees to a the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions f Title t n tat Code and not to place the system in operation until a Certificate of
Compliance has been issued b this r Halt
Signe Date .07
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
asa - loq
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is Centerville -t/ MA 02632 05/03/2021
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Imngoutf rms A. Inspector Information
filling out forms
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key. 52 Rivers End Road
rQ Company Address
Teaticket Ma. 02536
City/Town State Zip Code
508-280-3356 S13938
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
05/04/2021
Inspector'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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is Centerville MA 02632 05/03/2021
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This 3 bedroom home has an H-10 1500 gallon septic tank with an H-10 D-Box feeding a 15'x 30'
leaching trench with infiltrators. At the time of the inspection no visible failure criteria was found.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. 82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. Cityrrown 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
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. CityrFown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. City/Town 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 Y 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 f -
❑ ® y p g y g o 0 2000 g pd
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If have
you
y a e answered yes to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® 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
P P
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
Title 5 Official Inspection Form
F; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. Cityrrown State Zip Code 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): 333 GPD
Description:
.Number of current residents: 1
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): town water
Detail
In 2020- 124,000 gallons were used and in 2019- 140,000 gallons were used.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. Citylrown 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:
01/02/2002
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 14"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.tl 82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 3"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: H-10 1500 gallon
Sludge depth: 2„
Distance from top of sludge to bottom of outlet tee or baffle
34"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
0
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert.
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of.18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
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:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1 - 15'x30'
w/infiltrators
❑ 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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is Centerville MA 02632 05/03/2021
required for every
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.):
At the time of the inspection no visible failure criteria was found.
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.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. Cityrrown 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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. Citylrown 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
ywbs,a.d
Dr .'ve
0
T�j?
. I ,
f I
I
0
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
• Commonwealth of Massachusetts
p, Title 5 Official Inspection Form
P
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is required for every Centerville MA 02632 05/03/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:
90"
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: Aug 1, 2001 Perk Date
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:
Bottom of leaching is 38". This gives 4 plus feet of seperation.
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
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
yy Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,b 82 Lakeside Dr East
Property Address
Claire Anderson 2000 Realty Trust
Owner Owner's Name
information is Centerville MA 02632 05/03/2021
required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
TOWN OF BARNSTABLE E 'Q
LOCATION 9;Z L A i� e SW C .a X. A A 5 ' SEWAGE # 20� l 7� 3
VILLAGE C e N.-1',e9 V B//e ASSESSOR'S MAP & LOT ZSa
INSTALLER'S NAME& PHONE NO. T of Al A C 0 ,M /S @ R t- S C)M
I SEPTIC TANK CAPACITY o Q
LEACHING FACILITY: (type) 0, IAI ,CIZ 1�, hTo (size) 3
NO. OF BEDROOMS 3 rs vF 9)
BUILDER OR OWNER dy l ► �qt fro,?
PERMITDATE: A h//,)) COMPLIANCE DATE: D &Z,/,.-Z
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 leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�l
I.
�, Fee 50.00
� No. ` a - v t�✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[ppYication for ;Siopozal Opztem Conotruction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( YARComplete System 0 Individual Components
Location Address or Lot No.82 Lakeside Drive E. Owner's Name,Address and Tel.No. M Anderson
Centerville,Mass.02632 82 Lakeside Drive East
Assessor's Map/Parcel y Centervi l l e,Mas s.0 2 6 3 2
Installer's Name,Address,and Tel.Nos 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No5 0 8
Po
P.Macomber & Son Inc. Arne H. Ojala
x 66 Center.ville,Mass.02632 Down Cape Engineering
Type of Building:
Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
See plan
Nature of Repairs or Alterations(Answer when applicable) 1 -1 5 0 0 gallon septic tank
1-distribution box.2-rows of 4 standard infiltrators 3 ' of stone
on tne sides 3. 31between rows. on the ends.Remove impervious soils
and repa ce with clean per—Rabie sand.
Date last inspected:
Agreement: x
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is ed by thi Bo d o ealth.
Signed Date 12/1 1 0
Application Approved b Date l
Application Disapprove for a following reasons
Permit No. Date Issued
00
No: Fee /
THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer: ✓t/
Yes ..
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
s 01pp iratio.n for ogal *p5tem ConfStrurtion Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( X)CRComplete System ❑Individual Components
Location Address or Lot No.82 Lakeside Drive E. Owner's Name,Address and Tel.No. M Anderson
Centerville,Mass.02632 82 Lakeside Drive East
Assessor'sMap/Parcel .� _ lot/ Centerville,Mass.02632
Installer's Name,Address,and Tel.Nos 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No5l 0 8
.P.Macomber & Son Inc. Arne H. Ojala
11ox 66 Centerville,Mass.02632 Down Cape Engineering
Type of Building:
Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other 'Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. ,F
Description of Soil --''
See plan
Nature of Repairs or Alterations(Answer when ap lkable) 1 —1 500 gallon septic tank
-distribution box.2-rows of 4
1-:distribution infiltrators 3 of stone
an e st es etween rows. on trie en s.Remove impervious soils
and epa- ce with clean -perkanle sand.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage"disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed by thi Bo d oHealth.
Signed Date 12/1 1 Q 1
Application Approved b O Ul ��' Date ,
Application Disapprover for a following reasons y }
Permit No. C/ '2 Date Issued
--------------------------- .
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certiftrate of Comphanre
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(XX)
Abandoned( )by J.P.Macomber & Son Inc.
at 82 Lakeside Drive East Centerv.ille,Mass. �ja
constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Noated
Installer J.P.Macomber & Son Inc. Designer Ar
The issuance of/this permit shall not be construed as a guarantee that the system will function as designed.
Date A I 112 1 I Inspector rr n:ti/ i1�• /pi ,,'!r'"✓.
tV
± - THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi5pogar *pgtem Congtrurtton Permit.
Permission is hereby granted to Construct( )Repair( )Upgrade,,'M Abandon( )
System located at 82 Lakeside Drive East Centerville,Mass.
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constructio, must Ve completed within three years of the date of 's-die 't.
Date: Approved by
j TOWN OF BA.RNSTABLE F-C-
LOCATION 9';Z L,A,� e S°%Q e .Q9, 9.A -T Z" SEWAGE #
VILLAGE G e N '-ede V 1//P ASSESSOR'S MAP & LOT 25-1 'Jd
INSTALLER'S NAME& PHONE NO. Al A C O Al 11 Ca R I- S p M
SEPTIC TANK CAPACITY _ % S—® 0
LEACHING FACILITY: (type) 1W o'/C'fR,+T _ /f'S(size) t9
NO. OF BEDROOMSx vF )
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
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 leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
41
-T FF7
.1
R.
TOP FNDN E.L. 43.1' SYSTEM PROFILE TEST HOLE: LOGS -� -
_._.__.__� (NOT TO SCALE)
ACCESS COVER TO WITHIN 6' OF FIN, GRADE
ACCESS COVER (WATERTIGHT) TO ENGINEER: AH OJALA, PE
WITHIN 6' OF FIN. GRADE GL ENN HARRINGTON, RS
MINIMUM ,75' OF COVER OVER PRECAST /� �"/. SLOPE REQUIRED OVER SYSTEM 42 O' WITNESS_ �
*NOTE, PROPO5 DD�FbF� - !
AUGUST 1, 2001 � � C04nf,1° tis
BETWEEN INVERT IN AND INVERT PIPE LEVEL 2' DOUBLE WASHED PEASTONE� DATE: < 5 MIN/INCH IN L.S l I tiF��RO
41 �0' PERC. RATE + LOCUS
^_. . -
(PROP) � , PrnPClsEn 1, 0 * rFOR
\ 3' MAX. - ° s
�7J GALLON SEPTIC 40.90� 41.0' CLASS I __ SOILS P# p LAKEMEW AVE.
TANK (H- 10 ) GAS L40.66'
0
-'LJ �cx�cxa _
BAFFLE
1% SLOPE cx�``�- � � LAKESIDE DR. EAST
40.5i3/4' TO
�' Q ELEV. '
6' CRUSHED STONE OR MECHANICAL -' ' -�
42.0'
_ _ - 1�4 4� o' 2.Q v
COMPACTION. (15,221 121) go$g __ 0 40.0'
DEPTH OF FLOW = 41 ( 1 % SLOPE) (1�"/. SLOPE)
TEE SIZES 1/2" DOUBLE WAS HE=II `:s7E]NE FILL FILL WE°UA°UET LAKE
INLET DEPTH = 10"
" 90'
OUTLET DEPTH = 1q _ obs. water 34.5' 90" obs. wooer 34.5' LOCATION MAP NOT TO SCALE
5.
12' ST 7' D' BOX 10' LEACHING FILL SANDY LOAMORGANIC ASSESSORS MAP 252 PARCEL 104
IC
FC7UNDA1 IEJN~-- FACILITY SANDY LOAM
EL. 35.0' 10YR 2/1 10YR 2/1
(HIGH G-W ,
NOTE: THIS IS A PROPOSED INVERT OUT ELEV., 72" °BS. WATER 35.0' i'i sJ 32•�
FOR RE-ROUTED PLUMBING. CONFIRM WEQUAQUET 120" 32.0'
FEASIBILITY PRIOR TO INSTALLATION OF LAKE DATUM) � LOAMY
ANY PORTION OF SEPTIC SYSTEM, (BOTH GLEYED SAND
EXIT LINES MUST EXIT AS SHOWN, AT AN LOAMY FINE
ELEVATION WHICH IS 22" BELOW TOP OF SAND 2.5Y 4/3
FOUNDATION). PROVIDE PROPER SOIL 5/10Y
COVER OVER PIPING, OR PROVIDE 120" Ise" 28.0' 159.E" 28.7'
INSULATING BLANKET
1a�.ao' NOTES
..;.. WFQUAGUET ' AKF DATUM SYSTEM
LOT 124 'EP-i lC DESI I�: (GAiRE"AC ;>i'J3Lm ;a ALLOWED T J' NOT - _ ) I I `
13,890± SO. FT. DESIGN F �-OW. 3_ 13 DR? l 1S (1.1_�?..._GPII) - 33 ( f'D 2. 4UI ITCIPAI,. WATER IS.. EXI � ING �
{-a1. 'USE A 330 GPD DESIGN F_DW S. MI( IMUM PIPE PITCH T[J �_' 1/8" PER �..."J']-:`
TH 2 �` •SEPTIC T ANK: 330 GPD ( 2 ) 4. ))E:>IGN LOADING FOR ALL PRECAST UNIT; T❑ BE AASHCJ H-10
5' REMOVAL OF UNSUITABLE SOIL 5, "IF'E- JOINTS TO BE MADE WATERTIGHT,
+41.7r; +4100 REQUIRED AROUND PERIMETER OF USE A 1500 GALLON SEPTIC TANK 6, CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
LEACHING FACILITY, DOWN TO ENVIRONMENTA'` CODE TITLE V.
� LEAN
1 SUITABLE SOIL LAYER C H-I-�=
(APPROXIMATELY tO' DEEP). REPLACE NI �A 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND N'.aT TO BE
WITH CLEAN MED. SAND. ENGINEER SIDES USl_D FOR LOT LINE STAKING.
J TO INSPECT AND CERTIFY REMOVAL. BOTTOM 30 x 15 (.74) - 333 8. PIPE FOR SEPTIC SYSTEM TO SCH, 40-4" PVC.
I �
I ITH3 TOTAL: 450 S,F, 333 GPD 9, CC,MPDNENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
2.1F3 + 3.01 INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
USE 2 ROWS OF 4 STANDARD INFILTRATORS EACH, FROM BOARD OF HEALTH.
WITH 3' STONE AT SIDES, 3.3' BETWEEN ROWS AND 10. P! MP & REMOVE (OR FILL W/CLEAN SAND) EXIST. SEPTIC SYSTEM
PROP. 1500 GAL. SEPTIC TANK ^2.5' AT ENDS.
<r
42, 5 PROP, RE--ROUTED PLUMBING EXIT
EXIST. EXIT PIPING EXISTING DWELLING
TOP FNDN = 43.1' 100.0 PROPOSED SPOT ELEVATION OF - T�-'
t +a2.o1 82 LAKESIDE DRIVE BAST
Ea42.2E `�_ 11
��- EXIST. EXIT PIPING N IOOXO EXISTING SPOT ELEVATION
IN TI-.'E TOWN OF:
og PROPOSED CONTOUR ( CENTERVILLE ) BARNS-I-ABLE
---
�' 100 EXISTING CONTOUR PREPARED FOR:
+4 a2.21 - M /M ANDERSON
O
W EXIST. ST -I-a 2.05 20 0 20 40 60
L (5umutL 10)
- .78 /H1 � BOARD OF HEALTH
MA SCALE: 1" = 20' DATE: AUGUST 4, 2001- -
� .47 tPPROVED DATE REV. 1' /1/0,
1
ofP 508-362-4541
( �, 06. 24 Q� fax 508 362-9880
OF
down cape engineering, inc, AnNE M. , Of
BENCH MARK - CTR. OF C.BASIN
�40.4 c 07 EL. = 39.84' CIVIL ENGINEERS y L
w ZA ACT s� -1-4 y LAND SURVEYORS
RA S -t 39,97 939 rain st. yarmouth, ma 02675L, L.S.