HomeMy WebLinkAbout0066 PLEASANT PINES AVE - Health 66 Pleasant Pines, Centerville
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No. 42101/3 ORA
ESSELTE
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0 O O O
TOWN OF BARNSTTABLE
rBUILDER
I0Y1 � 4AT SEWAGE # 1GEASSESSOR'S MAP &LOV13
LLER'S NAME&PHONE NO. fro d �.s z.. 7.S'--4- 7 4
TANK CAPACITY S 6NG FACILITY: (type) - S-2 L C (size)/G S�-:�BEDROOMS A bL% bi ow
OR OWNER
PERMIT DATE: COMPLIANCE DATE: `3 1
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Botto" of Leaching Facility Feet
Private Water Supply Well and Leaching Facili (If any wells exist
on site or within 200 feet of leaching faci ' ) Feet
Edge of Wetland and Leaching Facility(If y wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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/. FORM 30 C&W HOBBS&WARREN'M THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
CITY/TOW N
o ^ _ DE ARTMENT_+. ''
ADDRESS
GSM 5 ey`oW
TELEPHONE
Address _-- TELEPHONE
Floor Apartment No. No. of Occupants___�L
No.of Habitable Rooms_ No.Sleeping Rooms _jt
No. dwelling or rooming units No.St ries p
Name and a dress o owner
f`( N , 6 Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
11110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1 .
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other.-
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJ HY."
INSPECTOR TITLE
1 A
DATE 0 r�
-o TIME P•M•
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
.. .. .. h,...:.Yar%+, '•„_,m-.. nY'..a.7:,""2"v�:..
_
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case'of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating,gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
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TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date 17 l°11 Zo1Z Time: in Out
Owner Tenant
Address "\ � ��. Address 60 PL1C4SA'iv—% I'inr S �'1✓�
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities Aomnvwt 17
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal J
16. Sewage Disposal
17. Temporary Housing
18. Driveway Width
19. Number of Tenants Observed
PART II
y, 37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehi II ed (max)
Number of Persons Allowed (max) Z
Person(s) Interviewed WNT Inspector
If Public Building such as Store or Hotel/Motel specify here
No. ._ fIJ Fee $ 0 V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Mi5pogal *pgtem Congtruction Permit
Application for a Permit to Construct(x)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Locati n d s or Lot No. per' N dress T o.
66..� �Pleasant Pines Ave
ai�`"ei, ng `iec
Assess6?s,Map/Pa11e1 Centerville 76 Chuckles Way, Marstond. Mills
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. 5. Robinson Septic Service
P 0 ox 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms Z 1 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 S and.
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system, consisting
of a tank, D-box and. 2 concrete leach chambers pith stone all
around..
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 issued by Board of Health.
Signed --� `�'~' Date_77
".F-, a-G--t)
Application Approved by Date 3—if ZdZ'"-D
PV
Application Disapproved for the following reasons
Permit No. 7,6'c/a 3 Date Issued 3 Zd'`sv
No. ....-- J b Fee�50 V
THE COMMON W � ,,� ' -OF MASSACHUSETTS Entered in computer:
M Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEj.MASSACHUSETTS
G
ZIpprication for ;Bigpont *p5tem Construction Permit
Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components
Locati n dress or Lot No. Offge ,s.N�me,.�d¢re,,�s ande el.aN0.
As ,X Pleasant Pines Ave 76 Chuckles Way, Marstond. Mills
Centerville
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
m. F,. Robinson Septic Service
P 0 ox 1089, Centerville
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 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 Sand
n n •t
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system, cons ist in _
of a- tank, D-box and 2 concrete leach chambers gith stone all
around .
-, 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 issued by t ;9,ard of Health.
Signed _ Date,�`-� b-�U
Application Approved"by, Date 3—
Application Disapproved for the following reasons
Permit No. 7,6-00" 3�c Date Issued 3 Zero
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Langf ie ld
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( X )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
at 66 A & B Pleasant Pines Ave. , Centerville has been constructed in accordance
with the provisions Hof Title 5 apd the for Disposal System Construction Permit No. 24ZW—CC dated—]/V
Installer
Wm. E . Robinson Sf.
Designer ;
The issuance of this permit s all not a construed as a guarantee that the s ste 1 function a�t sign +? c q
Date 1 Inspector
——————1 —————————————————————————————————
�No. v— IJ6 Fee $50
3 g r G/U_X6 p THE COMMONWEALTH OF MASSACHUSETTS
Langf ie ld
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Ofi5pozat *p!5tem Congtruction Permit
Permission is hereby gransa to Construct( )Repair( X�_)Upgrade( )Abandon( )
System located at b0 A & B Pleasant Pines Ave . , Centerville
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: Construction must be completed within three years of the date of this ell
Date: l/ �� d Approved by A4" - j
116/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, W i l l iarn E . Robinson,S,rhereby certify that the application for disposal works
construction permit signed by me dated 6-e-2) , concerning the
property located at 66 A &B Pleasant Pines Ave , Centemvdtilaofthe
following critetia:
• e failed system is connected to a residential dwelling only. There are no commercial or business
s ociated with the dwelling.
We s tl is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per,inch.
ere are no wetlands dithin t00 feet of the proposed septic system
f
re• r no private wells within 150 feet of the proposed septic system
ere is no increase in flow and/or change in use proposed
• Th a are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation: f Adjust the groundwater table using the Frimptor
method when applicable)
If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) cJ
B) G.W. Elevation +the MAX. High G.W. Adjustment - -
DIFFERENCE BETWEEN A and B
SIGNED : DATE: _ �a
[Sketch proposed plan of system on back).
q:health folder:cen
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TOWN OF BARNSTABLE
LOCATION -f A� 19, 01 -sSEWAGE #1 G v C 13 Z-
VILLAGE %. ASSESSOR'S MAP & LO-1 ` —o �'
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INSTALLER'S NAME&PHONE NO. 70 :A-A C 7 �S— 7 � 4
SEPTIC TANK CAPACITY /S o to
LEACHING FACII.ITY: (type) L C. (size) /C,—;2 S —A
NO. OF BEDROOMS Z
BUILDER OR OWNER /—
PERMTTDATE: :3 COMPLIANCE DATE: 3 — 1
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facilio (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
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= ' CO.M_MON-WEALTH OF MASSACHL;SETTS
EXECUTIVE OFFICE OF ENVIRONME.TAL AFFAIP.`
-• _ F DEPARTMENT OF ENVIRONMENTAL PROTECTION
gr ONE WINTER STREE':. BOSTON AL-1 021Ot (61" 292-550u
TRL DY CONE
Secreta_rY
ARGEO PALL CELLUCCI DAVID B STR'-*HS
Governor Corti.-nissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:66 a & b Pleasant Pines A Name of Owner David. Lan gfield.
Centerville Address ofOwner:T6 Ehu.ckles Way, Marstons Mills
Date of Inspection: 3 —/
Name of Inspector: (Please Print)Wm. E . Robinson Sr.
I am a DEP approved system)inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
company Name: Wm. E . Robinsoneptic Service
Mailing Address: PO Box 10d9, Centerville . MA
Telephone Number:
CERTIFICATION STATEMENT
1 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 sews edisposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: � i--n
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 tfre
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
N
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rev-*Lsed Page IofII
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• ^!ed on Rea-clyd Panr,
• J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A J
CERTIFICATION(continued)
'ropwlyAddress: 66 a' & b Pleasant Pines Ave . , Centerville
Jwner: David. Langfield.
Date of Inspection:
INSPECTION SUMMARY: Check �B, C, or D:
A. SYS PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. S TEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
ompletion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate y s, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If "not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box 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 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
revise-6 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property address: 66 a & b Pleasant Pines Ave . , Centerville
Owner: David. Lan field.
Date of Inspection:
D. SYSTEM FAILS:
You mu indicate either "Yes" or "No" to each of the following:
I eve determined that one or more of the following failure conditions exist as described in 310 CMR 15.3*03. The basis for this
d ermination is identified below. The Board of Health should be contacted to determine what will bi necessary to correct.the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or-clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
1 Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE YSTEM FAILS:
You must in icate either "Yes' or "No" to each of the following:
Th following criteria apply to large systems in addition to the criteria above:
T e system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
h alth and safety and the environment because one or more of the following conditions exist:
Yes
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)
The owner or perator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the apartment for further information.
it
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop"Add►es:: 66 a & b Pleasant Pines Ave . , Centerville
Owner: David. Lan,--field
Date of Inspection: .r�'2
C. RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
11 YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 I1)(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS 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 from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
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i
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Property Address: 66 a & b Pleasant Pines Ave . , Centerville
Owner: David. Langf ie ld.
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes/ No
Pumping information was provided by the owner, occupant, or Board of Health.
— None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
— As built plans have been obtained and examined. Note if they are not available with N/A.
— The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
— The site was inspected for signs of breakout.
V — All system components, excluding the Soil Absorption System, have been located on the site.
— The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
(/ — Existing information. For example, Plan at B.O.N.
— Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
/ [1.5.302(3)(b)]
-
The facility owner land occupants,if different from owner) were provided with information on the proper maintenaaraof
SubSurface Disposal Systems.
rev sea 9/2/98 Page Sorll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'rop"Address: 66 a & b Pleasant Pines Ave . , Centerville
Owner: David. Langfield.
Date of Inspection: 3 ®/.,0
FLOW CONDITIONS
RESIDENTIAL:
Design flow: �2�4p.d./bedroom.
Number of bedrooms(de3ignl: Number of bedrooms (actual):
Total DESIGN flow 0
Number of current residents:
Garbage grinder(yes or no): &o
Laundry!separate system) (yes or no)AQ); If yes,separate inspection required
Laundry system inspected (yes or no)
Seasonal use !yes or no):z4--'- 0
Water meter readings, if available (last two year's usage(gpd):_� �� 0 gal_• (vacant
Sump Pump(yes or no): v 1998 89, 000 gal.
Lest date of occupancy: . —L2 02 er�
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd 1 Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS an source of information:
System pumped as part of inspection: (yes or no)ff1 ZJ
If yes, volume pumped: gallons
Reason for pumping:
TYPE O 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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: /Q. •• .3 Q-�.Q
Sewage odors detected when arriving at the site: (yes or no)Ac d
revised G/2/10E Page 6(if 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(confined)
'topertl,Address: 66 a & b Pleasant Pines Ave . , Centerville
Owner: David. Langfield.
Date of Inspection:
BUIL NG SEWER:
(Locate n site plan)
Depth b ow grade:_
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comm (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grader /Material of construction:i/concrete_metal_Fiberglass _Polyethylene_otherlexplain)
If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions:
Sludge depth:0
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom f outlet to or baffle:L
Now dimensions were determined: "- ` ,w—
comments:
(recommendation for pumping, condition of inlet and outlet tees r baffles depth of�°'quid level in relation to outlet inver structuy integrity,
evidence of leakage, etc.) C'��C�
r
iLA
GREA TRAP:
(locate n site plan)
Depth bel w grade:_
Material o construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensio s:
Scum thi ness:
Distance rom top of scum to top of outlet tee or baffle:
Distan from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Comm nts:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
eviden of leakage, etc.)
revised Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
iropeny Address: 66 a & b Pleasant-,'� Pines Ave . , Centerville
Owner: David. Langfield.
Date of Inspection j7,j)A a-C--e,
TIG TOR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate n site plan)
Depth be ow grade:_
Material f construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain)
Dimensi s:
Capacity gallons
Design ow: gallons/day
Alarm p esent
Alarm I vel: Alarm in working order: Yes_ No_
Date o previous pumping:
Com ents:
Icon ition 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 level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP C MBER:_
(locate on site plan)
Pumps in orking order: (Yes or No)
Alarms in working order(Yes or No)
Commen s:
(note co dition of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
4op"Add►ess: 66 a & b Pleasant Pines Ave . , Centerville
Owe: David. Langfield.
Date of Inspection: '? &
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:L
leaching chambers, number:
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, si ns of hydraulic failure, level oo onding, damp soil, con tion of vegetation, etc.)
C SPOOLS:_
it
a on site plan)
Numbe and configuration:
Depth-t p of liquid to inlet invert:
Depth o solids layer:
)epth o scum layer:
Dimensic ns of cesspool:
Material of construction:
Indicatioi i of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm nts:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate o site plan)
Materials f construction:
Depth of olids: Dimensions:
Comment :
(note con ition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cortonued)
Nop"Address: 66 a & b Pleasant Pines Ave . , Centerville
lwner: David. Langfield.
Jate of Inspection: /2•�
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i
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e
1
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dal,
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revised 9;2/9R Page 10of11 l3
r SUBSURFACE S
E1IVAGE DISPOSAL SYSTEM INSPECTION FORM
tOPertMM PART C
Owner: Address: 66 a & b PleasanfynAMORMAT1ON(cortd� )' Owrrer:
Date oflnspedon: David. Langfield Ave . , Centerville
NRCS Report name
Soil TyPe
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow.
SITE EXAM Moderate
Slope Deep
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater is Feet
Please indicate all the
. methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V Observed Site(Abutting Property, o
y bservatiori hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you establ shed the
l� J) High Groundwater Elevation, (Mu
�be completed)
_sec 9/2/96
PaR�11 Of]]
i
i I
+ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifiratr of Tontlatiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X )
by ......W.E. .Robinson...Septic Service... - - ------
_...
66 Pleasant Pines Ave Centervill.e----------------------------------------------- -----
at ----------------------------------------- ........... ............---..---------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _. dated _-- - P_-.....-�--.....-..._.
PP P �'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUE AS�A/ GUARANTEE THAT THE
SYSTEM LL FU C�ION AT SFACTORY. (/
r^�
DATE... ... .................................. InsP ce�tor - �✓ �.... . ..
--_.------------------•---•---------------- ----_,__.---_- —_.- --__.-.
Langfield
30 .00 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�f TOWN OF BARNSTABLE 30.00
�i nstt1 urkii Tomitr tilon "rrmit
W.E. Robinson Septic Service
Permissionis hereby granted------ - ------------ -•--•-•----•-•------•-------••------•-----------•-•-----•••....----•------------------•............-•-•-----........
to Construct ( ) or Repair ( X) an Individual Sewage Disposal System
atNo. F'6 ..............................................aa - -----------
Street ry DD
as shown on the application for Disposal Works Construction Permit No., .... Dated...... a.:- _.:: 4...........
.......................... .....-.. >
.� `.1 Board of Health
DATE �''fY .......�_...
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
TOWN OF BARNSTABLE
LCCA?'-Jt N ro �o t /60SWIL"I TiktS �✓& SEWAGE # 99 79R
VILLAGE CC.-Wt-p V111 ASSESSOR'S MAP &4b�I��Aldd"7"��
INSTALLER'S NAME&PHONE NO. W e PQb['r P S®M S, QFiC_ -77 5=-777
SEPTIC TANK CAPACITY 1. Bt 0 4A Sf
LEACHING FACILITY: (type) Pf T i,d o Q 4, (size) 3 t 5k#-e
NO. OF BEDROOMS o�
aVU=DER OR OWNER kel 40'-�l_ Z . A1 f- ^
PERMITDATE: Q COMPLIANCE DATE: ZbO&
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching lityj Feet
Furnished by -,L ��
m mns(Z:-
eAck-
3a
rao
Fps......30 00....'...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
A .���!trtttiu�t for �l�p� ,1`
iu! Mirkg Tumitrurfiui! Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at: Ave
66 Pleasant Pines Centerville
------ -------•-•....•-•-----•----••......•••....•-----•---•-•---•••-•••••-•-------------.._... •--••--•--•••----•-•------•-••----•------------•-••-•-------------._...-----••-----•--............
Location-Address or Lot No.
David Langfield
--- .......... ........••--......-•-•-- •--•-••---------•-----....................-••-•.....
Owner Address
a W.E. Robinson Septic Service P.O. Box 1089 Centerville
----------- -----------------------------------------------••----------------- -----------
Installer Address
Type of Building Size Lot..---_-----------_--_---Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ---------------------------- No. of persons-.-.---..-.--.----.--------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow----.-...---------_ -- _.-.................gallons.
WSeptic Tank—Liquid capacity............gallons Length---.-------..... Width---------------- Diameter.------.-..----- Depth--------------_ x
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 ( )
aPercolation Test Results Performed by............ ............................................................. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.....--------.-.--.- Depth to ground water........................
fX Test Pit No. 2................minutes per inch Depth of Test Pit.-..------..-------. Depth to ground water........................
a ........................... ---•---••---•--••-••-•-•----•••-•••--•--•---•-•.............•---•-----••.........................................................
Description of Soil sand
......................................................................................................................................................
U
w
x . ----•-
U Nature of Repairs or Alterations—Answer when applicable..--in.stall...a....1--, 000....gal...tank......................
d-box & a stonep.acked leachpit. /
••• •-•--•-• ......-• ••--•.... .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued the board of health.
Signed .......`Z ..t......... . .........
..................................... -------------------------------------
Application,
A roved B e
Approved Y ......... x. - Date
Application Disapproved for the following reasons- ------------------------------------------------------------------------------- ---------------------------------------------------
............. ................................................... . ... ....................
Due
Permit No. ........7,5--------- .� .............. Issued
Dace
D 4
No.._.�l �� F.Hs..3.n...�®..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration fnr Bi-tipm3al Workti C ontitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at: Ave
66 Pleasant Piney Centerville
Location-Address or Lot No.
David Langf iela_.__..__-_-
_.. ..
W W.E. Robinson Septic Service P.O. Box 1089 Centerville
----•---------•...............•-----•-•--...------------------------------•----------•-•--•_------ --•••---•-•---------••••••---•---•••-------------•-•------••-•-----•---••-----•••--...............
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures _______________________________ _ _
d -- ----------------------------------------- ---------------------------------------------------•---------
W
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------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 ( )
Percolation Test Results Performed bY------- -----------------------------•-------------------------••-•--.--_. Date........................................
aTest Pit No. 1________________minutes per inch Depth of Test Pit_____________---_- Depth to ground water!.......................
�Zq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-._.___.-_.__-..._-___.
1:4 ----------- -------------------------- ......................................................................................................................
0 Description of Soil.................sand............................................................................................................................................ r
x
V
W
x ............--............... --------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable.--_install _a-_1_,000 dal.__tan.k,•-_--._--•-•-•--•-.•.
d-box a stonepacked.... eachpit.._ ,/�O. . ....__
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued bv the board of health.
Signed ....... ------ ..... ------------------------------------------3
Date -- ------...
Application.Approved B -.-...:). [ �.� ,.....,.-------------------------------------------- -- Date
Application Disapproved for the following reasons: ----- .. .................... .. ............................_..------------------------------
- --
--------------------------------------------------------------------------- ---------------------------------- ---------------------------------------------------------------------------- .............. . --
Permit No.. Date
-------- /.�....'.-..----- �1- --------------- Issued ----------------------
Date
B
� ��
S-5
�8 � .