HomeMy WebLinkAbout0614 OLD STRAWBERRY HILL ROAD - Health 1:.614 Old Strawberry Hill Road 1 0
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Commonwealth of Massachusetts
j: Title 5 Official Inspection form,.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville .- .. M -273 P -98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is 614 Old Strawberry Hill Road, CentervilleA 02632- Ma 5, 2021 t
required for every ry y '
page. City/Town• State Zip Code Date of Inspection
4 t
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector'Information S14t-r KL414
on the computer,
use only the tab Troy Williams
key to move your Name of Inspector
cursor-do not Troy Williams Septic Inspections
use the return Company Name
key.
ux
Hummel Drive _
Company Address
South Dennis _ - MA 02660
City/Town _ State Zip Code
� (508) 385- 1300 S1682
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 J.
'
3. ❑ Needs Further-Evaluation by the Local Approving.Authority
4. ❑ Fails
May 5, 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 andlunder the
conditions of use at that time. This inspection does not address how the system w_ill perform_
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
-, Title 5 Official Inspection, Form
R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville M -273 P -98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is `�`'�t "
required for every 614 Old Strawberry Hill Road, Centerville MA 02632 May 5, 2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
i
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes, '.','
Z I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.363 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, .
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
�_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):
t ,
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts r
Title 5 Official Inspection FormN
1= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville M -273 P-98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is
required for every 614 Old StrawberryHill Road, ery y
Centerville MA _ 02632 May 5, 2021
page. City/Town 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):
Eldistribution box is leveled or replaced El 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): -
ET broken pipe(s) are replaced Ej Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
a
1
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
f 15.303(1,)(b)that the system is not functioning in a manner which will,protect public health,-
safety and the environment: ' I
-
t5insp.doc•rev.7/26/2018 Title 5 Official inspection form:Subsurface Sewage Disposa6System•Page 3 of 18
Commonwealth of Massachusetts '
- Title 5 Official Inspection Form
i nsp
�j Subsurface Sewage Disposal System'Form Not for Voluntary Assessments,
614 Old Strawberry Hill Road, Centerville M_273_ P -98
Property Address
Edgar& Sue Carol Semprini _ 4
Owner Owner's Name
information is required for every 614 Old Strawberry Y
_wb Hill Road, Centerville MA 02632 May 5, 2021
— _ _
page. City/Town 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
1 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:.
v
4) System Failure Criteria Applicable to All Systems:
must You - indicate "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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts r
Title 5 Official Inspection Form .
I e Subsurface Sewage Disposal System Form Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville M -273 P '98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is 614 Old Strawberry Hill Road, Centerville MA 02632 May 5, 2021
required for every ry y
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cost.),.
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes. No.
❑ E 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 %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.
r ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® A,n onion of a cess oolror`J rivy is y p � p p less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
:. system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered..A copy of the analysis
and chain of custody.must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000_gpd-
r 10,000 gpd. _
❑ ® The system fails. I have determined tliat one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
f 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 C:4:,, r
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
11 El 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
�1� Subsurface iSewage Disposal System Form - Not for Voluntary Assessments
V � 614 Old Strawberry Hill Road, Centerville M -273 P -98
Property Address
Edgar& Sue Carol Semprini
Owner
information is 6_1.4e01_d_Strawber_ HillRoad_Centerville
required for every - -�! -- __. _ _ MA __ 02632__' May
—
page. City/Town State Zip Code Date of Inspection
C. Inspection'Summary (cont.) e
If you have answered"yes" to any question in Section C.5,the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the 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
❑ Z 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?
1
® 1. ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z, ❑ Was the facility'or dwelling inspected for signs cof sewage back up?
-E �❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were'the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
_, dimensions, depth of liquid, depth`of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ ` " Existing information. For,example,-a plan at the Board of Health.
® ❑. Determined in the field (if any of the failure criteria related to Part C is at issue
approximation'of distance is unacceptable) [310 CMR 15.302(5)]
L -
r 1 .
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
!} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville M -273 P -98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is 614 Old Strawberry Hill Road, Centerville MA 02632 May 5 2021.
required for every ry _ y
page. City/Town State Zip Code Date of Inspection
D. System Information I
1. Residential Flow Conditions:
Number of bedrooms.(des.ign.).: 3 Nu.mber of bed.roo.ms.(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Description:
Number of current residents: 2
J•
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? 0 Yes E No
If yes,'dischargesto: - N/A
Is laundry on a separate sewage system? (Include laundry system inspection - El Yes, ® No
information in this report.) ' '
Laundry system inspected? ® Yes ❑ No
Seasonal use? ' ❑ Yes ® No
Water meter read in s, if available last 2 ears usage d 20=52,0.00 gals.
• g ( y g (gpd)): 19=52,000 gals.
Detail:
. r
Sump pump? ❑ Yes E No.
Last date of occupancy: t - occupied
Date
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
614 Old Strawberry Hill Road, Centerville M -273_ P-98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is 614 Old StrawberryHill Road, Centerville MA 02632 May 5 2021
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow N/A(based on 310 CMR 15.203):s Gallons per day(gpd)
N/A
Basis-of design flow (seats/persons/sq.ft., etc.): - -
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: N/A
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
3. Pumping Records:
Source of information: No pumping info available.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: —
gallons
How was quantity pumped detef-Mined? -- ----
Reason for pumping i — -- -----
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
1' Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville - M -273 P_98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name -
information is r 614 Old Strawberry Hill Road, Centerville MA 02632 May 5, 2021.
required for every ry y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
z Septic tank, distribotio,n,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.1/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:
Tank, d-box and leaching were installed on 4/15/98 per compliance.
Were sewage odors detected when.arriving at the site? ❑ Yes E No
5.. Building Sewer(locate on site plan):
18"
Depth beloWgrade: feet
Material of constrdction: F i
cast iron �- • Z 40 P,VC '❑other(explain): - - ----
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Lines were found clear at the time of inspection.
` t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
1
Commonwealth of Massachusetts J
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments.
614 Old_Strawberry_Hill Road, Centerville M -273 •P -98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is
required for every 614 Old Strawberry Road, Centervilley �
_tber Hill MA' 02632 May 5 2021
_ —
page. City/Town State Zip Code Date of Inspection
r D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 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: 6'X10.5'X6' 1500 gallon
4"
Sludge depth —
2' 8"
Distance from top of sludge to bottom of outlet-tee or baffle —
t Scum thickness thin layer
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle • 16" —
How were dimensions determined? probe/measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage
was found.Tank was not in need of pumping at this time.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts t.,
Title 5 Official Inspection_ Form
'= � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............ 614 Old Strawberry Hill Road, Centerville M -273 P-98
Property Address -
Edgar& Sue Carol Semprini _ ..
Owner Owner's Name
information is
required for every 614 Old Strawberry Hill Road; Centerville MA 02632 May 5, 2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below, N/A grade: feet
Material of construction:r
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: - N/A -- _=_--=--
Date—
Comments (on pumping recommendations, inlet and outlet tee orbaffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete _❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
1 -
Dimensions: N/A
Capacity: N/A
gallons
Design Flow: N/Agallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments'
614 Old Strawberry Hill Road, Centerville _ M -273 P -98
Property Address
Edgar& Sue Carol Sernprini
Owner Owner's Name _
information is required for every 614 Strawberry y
_Old Strawber Hill Road, Centerville MA 02632 May 5, 2021
- -
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level:' N/A — Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.):
N/A
*Attach'copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present musf be opened) (locate on site plan):
Depth of liquid level above outlet invert level
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.):
D-box was found level and in working order with equal distribution to outlet lines. No evidence of solid
carry-over or backup in the past was found at the time of inspection.
r
f ..
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
I
Commonwealth of Massachusetts k£
Title 5 Official Inspection Form ,
1= io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville M -273 _ P -98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is 614'01d Strawberry Hill Road, Centerville MA 02632 May 5, 2021
required for every rY _ _ Y
page. City/Town A 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.):
N/A
f
* If pumps or alarms are not in working order, system is a conditional pass..
r
11. Soil Absorption System (SAS) (locate on site plan;excavation not required):
If SAS not located, explain why:
r
Type.
❑ leaching pits- number:
® leaching chambers number: 2.- 500 gallon
_ with 4 stone
Ej leaching galleries number:
25'X 12.8' X 2'
❑! leaching trenches number, length:
I
❑ 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
614 Old Strawberry Hill Road, Centerville M -273 P - 98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name y
information is 614 Old Strawberry Hill Road, Centerville MA 02632 May 5, 2021
required for every _ ry y
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.):
Soil was sandy. Chambers had a low water level present at the time of inspection. Checked stone
and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the
time of inspection.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A _
Depth of solids layer N/A , _
Depth of scum layer N/A —
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
i
t5irisp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s„
v 614 Old Strawberry Hill Road,,Centerville M -273 P -98
Edgar& Sue Carol Semprini
Owner -- -—— - --
Owner's Name ---:.._. .__---- -------- ---�__ ._----- ---...--
requir atifo is 614 Old Strawberry H
required for every .__:_ ry ill Road, Centerville MA 02632 May_5 2021 _
page. Clty/Town --- - Z--i p Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
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
t i� Subsurface Sewage Disposal System form - Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville M -273 P -98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name ------------._...----------_ _...
information is required for every 614 Old Strawberry Hill Road, Centerville MA 02632 May 5, 2021
---- ---_— --- --._."--...-------._..T__-- .-. _------ — - - - --
page. City/Town __ --- State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System;
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
14
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1:0 0
ap' 61%
9 ' 3 ` 3�
t6insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,- Not for Voluntary Assessments
614 Old Strawberry Hill Road, Centerville M -273 P -98.
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is 614 Old Strawberry Hill Road, Centerville MA 02632 May 5, 2021 `
required for every ry y
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: - 10.0'+
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: 1998
Date
Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain: -
❑ Checked with local excavators, installers-(attach documentation)
Accessed USGS database explain:
You must describe how you established the high ground water elevation:'
Test hole recorded on plan showed no water found at 10.0'. Bottom of leaching at 4.9'was found not,
to be located in the high groundwater elevation at the time of inspection. System installed to plan.
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
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c Commonwealth of Massachusetts f '
-- -, Title 5 Official . Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.,
/pP'J
1� '614 Old Strawberry Hill Road, Centerville M -273 P -98
Property Address
Edgar& Sue Carol Semprini
Owner Owner's Name
information is 614 Old StrawberryHill Road, Centerville MA 02632 May 5, 2021
required for every y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Z 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
Z 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
7
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
1
T%OWN OF BARNSTABLE 6-C.
LOCATION; �SEWAGE # 1
VILLAGE a..M4WJ4(939SSOR'S
MAP & LOT , G
INSTALLER'S NAME&PHO (?<.
SEPTIC TANK CAPACITY oo
LEACHING FACILITY (type) , (size)
f
NO.OF BEDROOMS =� `
BUILDER OR'OWNER
PERMTTDATE: =L 1_ 9 u COMPLIANCE DATE: !f I s -I S,�
Separation.Distance Between the:
I 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
S
a
No. -7 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYicatton for ]Digpogal *pgtem Comaructton Vermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) complete System O Individual Components
Location Address or Lot No.61 4 O 1 d Strawberry Owner's Name,Address and Tel.No.7 71 —0 4 7 9
Hilloaad Centerville,Mass. 02632 614 Old Strawberry Lane
Assessors ap/Pazcel A 73 Centerville,Mass. 02632
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.Ne?0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XXNo.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily now 3/1 10 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Loamy sand to fine Sand somewhat Boney
Nature of Repairs or Alterations(Answer when applicable) Installing 1 —1 5 0 0 gallon
tank.1 —Distribution box,2-500 gallon chmbers packed in
four feet of stone.
Date last inspected: 3/1 1 /9 8
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 issu 1,by this Board/of alth.
Signed 44 Date 3112/9 8
Application Approved by Date _k-J.6 J °4'l
Application Disapproved for the flowing reasons
Permit No. - f -71 Date Issued
I TOWN OF BARNSTABLE q
LocATibN / Ol�� ST jl r� SEWAGE# l 7
_4
VILLAGE_�U.�. a ASSESSOR'S MAP & LOT • O
INS.-'ALLER'S NAME&PHONE NO. 5,.p 6In
SEPTIC:?TANK CAPACITY Is oo S 1'
LEACIUNG FACiLrN: (type) a, (size)
NO::OF.BEDROOMS
BU"ER'OR OWNER
PE$iv1ITDATE:_Tk L . COMPLIANCE DATE:
Sepiiat�on Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Priate.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(1f any wetlands exist
;w:thin300 feet of leaching facility) Feet
Furnished by
94,
1 ± I
r
N No. t / Fee 5 0 0 Q0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Nof
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
Application for ;Diopozar *pgtem Con!6truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ®X;omplete System ❑Individual Components
Location Address or Lot No.61 4 Old Strawberry Owner's Name,Address and Tel.No. 7 71 —0 4 7 9
Hill Road Centerville,Mass{.-"�02632 ' 614 Old Strawberry Lane
Assessor'sMap/Parcel A 73 Q 9 ? Centerville,Mass. 02632
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.Nos 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 0 f :.; �. gallons per day. Calculated daily flow 3/1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type.of S.A.S.
Description of Soil Loamy sand to fine sand somewhat Boney
Nature of Repairs or Alterations(Answer when applicable) Installing 1 -1 500 gallon
tank.1 -Distribution box,2-500 gallon chmbers packed in
char feet of stone.
Date%fast inspected: 3/1 1 /9 8
Agreement's
rf 11
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in aceordan a with the provisions of Title►of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B pardof H alth.
Signed Date 3/12/98.
Application Approved byCZ
Date-%r
Application Disapproved for the lowing reasons
a
Permit No. 171 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
4
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgrade&(XX)
Abandoned( )by' Jr.P.Macomber & Son Inc. t
at 614 Old Strawberry Rill Road Centervitble,Mass. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system w'll fuji t on as designed.
Date — rftS- 9 Inspector l
---------------------------------------
No. - 1 7/ Fee$ 50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
xi0pozaf *pgtem (Con0truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade�(,X )Abandon( )
System located at 614 Strawberry Hill Road 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:Construction must be
ee}cormmpleted within three years of the date of this permit.
Date: Approved by Q" a
10/9/97
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
ENGINEERED PLANS)
I, Joseph P.Macomber Jr._, hereby certify that the application for disposal works
construction permit signed by me dated 3/12/9 8 , concerning the
property located at 614 Old Strawberry Hill Road meets all of the
Centerville,Mass.
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
4/ There are no private wells within 150 feet of the proposed septic system
V There is no increase in flow and/or change in use proposed
i/ There are no variances requested or needed. t
If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility
groundwater will=be located less than fourteen(14)feet above the maximum adjusted
table elevation.
Please complete the following: /
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) Q�/
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGN ED : DATE:
LIC,' D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 10
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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