Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0261 AMES WAY - Health
261 Ames Way Centerville A = 170 235 a No. 42101/3 ®RA vt ` 1000�` C r o ,r I ��' f �3 E. o r; :� 4 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r ,r 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S1 11 f�:H q on the computer, use only the tab Armando Pantoja key to move your Name of Inspector cursor-do not Accu Sepcheck use the return Company Name key. 17 de Drive � Companypant'Address South Dennis MA 02660 City/Town State Zip Code fermi, 508-385-5891 S1 14296 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 0/ � � J 7/27/2020 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 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 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: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional ss"section need to be replaced or repaired. The system, upon completion of the repl ment or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, N for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or a ration or tank failure is imminent. System will pass inspection if the existing tank is replaced h a complying septic tank as approved by the Board of Health. *A metal septic tank will pass i ection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that t 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 I Commonwealth of Massachusetts M Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 261 Ames Way, Centerville, MA Property Address Timothy & Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 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 o ealth approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water vel in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or even 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 /pipe ) g more than 4 times a year due to broken or obstructed pipe(s). The system will p (with approval of the Board of Health): ❑ brokplaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstd ❑ Y ❑ N ❑ ND (Explain below): 3) Fu er Evaluation is Required by the Board of Health: CondiConditions exist which require further evaluation by the Board of Health in order to determine if tions 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 261 Ames Way, Centerville, MA Property Address Timothy& Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 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 wetla or a salt marsh b. System will fail unless the Board of Health (and Public Wat Supplier, if any) determines that the system is.functioning in a manner that p tects the public health, safety and environment: ❑ The system has a septic tank and soil absorption syst (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surfa water supply. ❑ The system has a septic tank and SAS and the S S is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and e SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS nd the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: AQ **This system passes if the well w er analysis, performed at a DEP certified laboratory, for fecal colifoim bacteria indicates abse and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provide hat 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 ❑ ® 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 (/ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 4" n u 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 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 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no" each of the following, in addition to the questions in Section CA. Yes No ❑l ❑ the syste s within 400 feet of a surface drinking water supply ❑ ❑ t 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts M Title 5 Official Inspection Form I." Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is required for every Sagamore Beach MA 02562 7/23/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the 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? I nc� ® El Were all system components, ex 'ng 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. ® El approximation 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 Commonwealth of Massachusetts l� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is required for every Sag amore Beach MA 02562 7/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 for example: 110 d x#of bedrooms): 334 GPD ( P 9p ) PER PLAN Description: SYSTEM CONSISTS OF ONE 1000 GALLON SEPTIC TANK, ONE DISTRIBUTION BOX AND ONE SAS OF FIVE INFILTRATORS WITH 4' STONE ON THE SIDES AND 1.5' STONE AT ENDS. Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 92 GPD 9 ( Y 9 (9p ))� Detail: 2019: 36000 G ; 2018: 31000 G Sump pump? ❑ Yes ® No Last date of occupancy: 7/23/2020Date 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. 1- 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203). ZGallonsay(gpd) Basis of design flow(seats/persons/sq.ft., Grease trap present? ❑ Yes ❑ No Watertreatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial /tank tank present. ❑ Yes ❑ No Non-sanitharged the Title 5 system? ❑ Yes ❑ No Water mef ailable: Last date use: Date Other(de : 3. Pumping Records: Source of information: PUMPED 2018 PER OWNER 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts r^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy&Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 page. City/Town 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 es or no if es attach previous inspection records, if ❑ Y (Y ) ( yes, P P e 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: AGE: SEPTIC TANK IS AGE OF HOUSE APP, 41 YEARS. NEW DBOX AND SAS 19 YEARS ; INSTALLED 2001 ; SOURCE: PER ENGINEERING PLAN AND HD Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: —2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10 feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO EVIDENCE OF LEAKAGE PER OWNER(SEE ADDENDUM). t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r= Title 5 Official Inspection Form / Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6"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: APP 8.5'X6'X5', 1000 GAL Sludge depth: ' 4" Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness Oil 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 19" How were dimensions determined? CORETAKER Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NO RECOMMENDATION FOR PUMPING AS SOLIDS DO NOT EXCEED 20% OF TANK VOLUME. HAS PVC INLET TEE AND PVC OUTLET TEE. NO EVIDENCE OF LEAKAGE. LIQUID LEVEL IS 48". LEG LENGTH IS 19". t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy&Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 page. City/Town 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 ❑ polyethylen ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of o/leakage, e Distance from bottom of scum to bottor baffle Date of last pumping: A? Date Comments (on pumping recommenda outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, akage, etc.): 8. Tight or Holding T k (tank must be pumped at time of inspection) (locate on site plan): Depth below gra e: NOT APPLICABLE Material of co struction: ❑ concre ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): .Dim�Jn�sions: 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 f- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy& Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 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: arm in working order: El Yes ❑ No Date of last pumping: Date Comments (condition of alarm 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 AT INVERT Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DBOX IS IN GOOD CONDITION WITH ONE PVC PIPE IN AND ONE PVC PIPE OUT. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form M � 1- 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy& Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is required for every Sagamore Beach MA 02562 7/23/2020 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, condi ' of pumps and appurtenances, etc.): Y * If pumps or ala are not in working order, system is a conditional pass. 11. Soil Absor ion System (SAS) (locate on site plan, excavation not required): If SA not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1- <i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is required for every Sagamore Beach MA 02562 7/23/2020 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.): SAS CONSISTS OF 5 INFILTRATORS WITH 4' STONE ON THE SIDES AND 1.5'AT THE ENDS. SAS AREA IS 34'x11'WITH 10" DEPTH. SAS IS DRY. STONE IS CLEAN, DRY. GRADE TO BOTTOM OF SAS IS 4'. 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 groundw er inflow ❑ Yes ❑ No Comments (note c ndition 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 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: NOT APPLICABLE Dimensions NOT APPLICABLE Depth of solids NOT A ICABLE Comments (note condition of soil, signs o draulic failure, level of ponding, condition of vegetation, etc.): , NOT APPLICABLE t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy &Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is required for every Sag amore Beach MA 02562 7/23/2020 page. Cityrrown 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 t W l A g �EC{S 20 0 D/37AkGU 83=q0s' y H$ rya 72•s' .BY= kX5_1 3 - - r t5insp.doc•rev.712 612 01 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 >r� 261 Ames Way, Centerville, MA Property Address Timothy& Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is g required for every Sa amore Beach MA 02562 7/23/2020 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: 9.2 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: 12/6/2001 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: FRIMPTER, BARNSTABLE GWATER CONTOUR MAP 1992 You must describe how you established the high ground water elevation: PER DESIGN : NO GROUNDWATER AT 120" FOR DESIGN TEST HOLE DATED 10/11/2001. GRADE TO SAS BOTTOM IS 4'. NO GROUNDWATER ADJUSTMENT USED IN DESIGN. SITE IS —25'ASL WITH A MAX RISE OF 3.8'AND AN ELEVATION OF 38'ASL. GRADE TO SAS BOTTOM IS 4'. SEPARATION MATH: 38425+3.8+4)=5.2' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Ames Way, Centerville, MA Property Address Timothy& Katherine Sachs 25 Canal Road APT A3 Owner Owner's Name information is required for every Sagamore Beach MA 02562 7/23/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 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 COVID-19 Title 5 Inspection Addendum Due to the COVID49 pandemic, ACCU SEPCHECK will follow the following practices for your own and our employee safety: 1. We will not go into your house. 2.We will practice social distancing. 3. We will have a form for you to fill out and sign. These are required fields on the inspection form. 4. This form is available via email. You can email form back to joemartins@comcast.net. OWNER NAME: yK�i�tY1S date �o? -rlw4r.12-0 INSPECTION LOCATION: a 61 A Y1 LJQ I, OWNER,verify that the information below is correct: ,-.,,, OWNER SIGNATURE. . Please indicate the following for your resi ence: 1. How many bedrooms are present? (Bedroom definition: no less than 70 square feet,not a walk-through room(privacy),height no less than 7',electrical service and ventilation, at least one window) 2. Is there a garbage grinder?(YES/NO) �%\)0 3. Is the residence seasonal,meanin that it is inhabited less than 6 months per year?(YES/NO) 4. Current number of occupants: 5. Last date of occupancy: () 6. Is the laundry q000ected to di uilding sewer pipe?(YES/NO) WIA is the sewer pipe made of?(cast iron,k9c other) . Any evidence of leakage?(YES O 7. Is there a sump pump?(YES/NO) 8. Is there a water treatment unit? (YES • 9. Please include a sketched floor plan of your property, indicating Basements, all floors present,Living rooms, bathrooms,kitchens,dining rooms, etc. For unfinished basements,write"UNF" Al Iry Rev 6/8/2020 i Commonwealth of Massachusetts a3S-- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;P M 261 Ames Way Property Address 3� John Delellis CD Owner Owner's Name 14' information is CM required for every Centerville ✓ Ma 02632 6-1-16 page. City/Town State Zip Code Date of Inspection w. . A . Inspection results must be submitted on this form. Inspection forms may not be altered in'hy way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information / on the computer, C(/ use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation rQ Company Name 374 Route 130 Company Address r Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI 13747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-1-16 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 40��wvs. Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments nM 261 Ames Way Property Address John Delellis Owner Owner's Name information is Centerville Ma 02632 6-1-16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. Tank was pumped after inspection for maintenance. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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, 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must 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 ❑ ® 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 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 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. 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 If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(Actual) 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 334 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No 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 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2015-96,0009alIons 2014-70,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 261 Ames Way � Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumper driver-system pumped after inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Tank size Reason for pumping: maintenance 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^� 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6 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: 1000 Sludge depth: 8 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 4 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 13" How were dimensions determined? 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank was pumped after inspection for maintenance. Grease Trap (locate on site plan): Depth below grade: NAfeet 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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 is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up or carry over. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 5 HiCapinfiltrators ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Infiltrators were 'h full when inspected. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 261 Ames Way Property Address John Delellis Owner Owner's Name information is Centerville Ma 02632 6-1-16 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate on site plan): ( p ) Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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 REAR IA 8 NECK A -26' c-451" B Ae•647' Be•90r4 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW @ 120" 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: 11-27-01 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 261 Ames Way Property Address John Delellis Owner Owner's Name information is required for every Centerville Ma 02632 6-1-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSAC HUSETI'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OI. ENVIRONMENTAL PROTECTION Y, TITLE 5 OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PA 12T A C'EIi;TIFICAT'ION 26l Ames Way Pr,rpert) Address: , Centerville, MA Owner's Namc: Kathleen Djerf Owner's Address: 261 Ames Way i Centerville,MA . Dale of Inspection: June 28,2007 l -� C,._ ;ter 1 C= _ t Name of Inspector: Troy M. Williams =" �" Company Name: Troy Williams Septic Inspections ( r.3 Mailing Address: 19 Hummel Drive t' ! South Dennis,MA 02660 X Telephone Number: (508)385-1300 - CIO CERTIFICATION STATEMENTn r 1 I certify that I have personally inspected the sewage disposal system at this address and that the infort ration reported below is true, accurate and complete as of the lime of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP appro%ed sYstern inspector pursuant to Section 15.340 of Title 5(310 CM11 15.000). The systenr V Passes Conditionally Passes Needs f tinier [:valuation b) the Local Apptuving Aulhoru) Fails Inspector's Signature: �.t�R., / Date: 6 lag /(5 The systern inspector shall submit a copy of this inspection report to the Approving Awhority(Hoard of I lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. i Notes and Comments } Although system meets the minimurn requirements set forth by the Massachusetts Department of s1 Environmental Protection,certification is not to be construed as a guarantee of future working condition 1 of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. "•""phis report only describes conditions at the time of inspection and under the conditions of use at that i time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 paee I of II Page 2 of l 011 1('IAC, INSPECTION jeORM — NOf lii`0112 VOLUNTARY ASSESSMENTS SLJI1SU121(�ACI!i� St?WAGI", D!SP0SAij-, SYSTEM CN PEC`ION PORM 1!'Al2`I' A CM��2`11'�C?r�'A'p'r�QN (continued) Properly Address: 261 Ames Way Centerville,MA Owucr; Kathleen Djerf Date of llnspecIiou: .June 28,2007 Inspection S►uiuuary. Check A,",CI) or le,/ ALWAIVS colliplele all of Section D A. Syslew I'asses: l have not fixmd any infiiinialion which indicaies lhM ally ail the failure criteiia described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure crileria nol evalualed are indicated below. Conuuculs: it. System Conditionally t'asses: One o,more system components its described to Ilse"Conditional Pass"section peed to be replaced or repaired-The system, upon Col np let ioli of Ilse replaceinenl of repair, as approved by the Boar of I lealdi, will pass. Answei yes, no or not dele,mined(Y,N,Ni)) in file _fir the following slalement" f"not detemiiiied"please explain. The septic tank is metal and over 20 years old* or (lie septic kink (w the,metal or not) is structurally unsound, exhibits substantial intiltralion or exlilhation or tack.failure is uniuenl. Systerr►will pass inspection if the existing lank is►eplaced wily a complying septic tank as approved by ie Boaid of Health. *A metal septic lank will pass inspection il'it is slnu:Iurilly sound of lcakiug and if a Cerlificale of Coniplialice indicating dial lie lank is less Ihan 20 years old is available. ND explain: Observation Uf'sewage backup or break out,.,r high static waler level in the disliibulioti box due to broken or obstructed pipe(s)of due to a broken,settled or sever►distribution box. Sysicni will pass inspecliot)if(with approval of 13oij!-d of f lealth): brok pipe(s)are replaced -- o unction is removed c,istlibulion box is leveled or[eplaced N1)explain: The system re ►ell pumping more than I limes it yeaCiliie to broken o,obsintcted pipe(s).`rile system will pass inspeclionif( .th approval of the l3oar�l ill'lleullh): brokeh pipe(s)arc replacedf obstruction is removed Nq explain; 2 Y Page 3 of Of-+I(AA1. INSPECTION r010/j - NO')' eOlt VOL1JN`I'ARY ASSESSMENTS SUBSUR A(T SlI WAGE DISPQSAI, SYSTEM INSPECTION PORM Pik 14 A CIAZ"I'l11.CA-I'lON (continued) Properly Address: 261 Ames Way Centerville,MA Owner: Centerville, Djerf Dale of Inspeclioll.June 28,2007 — C. hurlllcr 1:valualiou is Itcquil-Ul by lilt! Ilia1-il of llcallh: _ Conditions exist w(lich IequilC lllrlbur eval.11allon by the lloal-il of I leallh Ill order to delel-nine if(lie sysiclll is failing to p,.olect public heallh, safely or lilt enviionnient. I. System will pass unless "nand of Ilcallh dcleru,►iucs in accoI tlalice Willi 310 CMIZ 15.3113 (l►) ilia( like syslen►is not f►ulctioning in a lf►aillier wlilcil will protect public heallll,safety and U►e vironnleril: _ Cesspool o,.privy is within 50 feel of a surface water Cesspool or privy is within 50 feel of a bol-deling vegelated welland of a sail arsll 2. Syslctit will tail unless life I3oartl of Ilealth (alld Public Wal , Supplier,if airy) lleleri ►fines Illat like syslclu is I'll ncliotlifig ill a nl:u►uer (Hilt protects (Ile pulllie he` 11,safely and euvironnleni: _ The syslen has it septic lack and soil absoiplion ' slcnl(SAS)and the SAS is within 100 feel of a surface wales supply ctr liibulary to a surtiicc watt► 111ply. 'fhc system has it septic tack and SAS a . , Ili(SAS is within it Lone I of a ptihlie wale,.supply. The sysitnl has if septic lank and 'AS and the SAS is wit1iiu 50 feel of a pfivate water supply well. flit syslen►has it septic lilt and SAS and the SAS is less than 100 feel but S0 fret or more frond a pfivate water supply well"* elliod used to delt,.nlinc distance ++'I'llis systeli'►passes the well wi►ler analysis, peilitrpled ill it f)rP certified laboratory, fol-coliform bacleria and vplali _ organic conlpotiuds indicales that tilt well is lice from pollulion lroul Thal filcilily anti the piesence of uporlia nil ogee and nittale rfitro6ep is equal to of less Ihan 5 ppm,provided lhat no olher failure crite ,1 arc ti iggertd. A copy of tilt analysis roust be attached lit lllis Form. 3. Olhcr: ' 3 Page-1 of I I nF1l,ICIA1, IINSJ'ECIJON FORM — No f fe()Ct VOLUNTARY ASSESSMENTS SUBSURFACC SI?'vVAGLe I)ISPOSA1 SYSTEM INSPC+C1'ION FORM 1.�A t'Jr A 1 1,111111VIC"A` ION (continued) 261 Ames Way Properly Addl,ess: Centerville,MA Kathleen Djerf Owner. .June 28,2007 Dale of lusptx(ion: 1). System hailtlre('rileria applicable to all systems; You 11111Sl indicate"yes"or"no" to eilch of llle following for all inspections: Yes No ,/ Backup of sewage info facility or syslen1 c0l"POnent clue to overloaded or clogged SAS or cesspool pisclkarge or poudiug of eltluenl to the surface of the ground or surface waters due to an overloaded or clogged SAS t►r cesspool ✓ Static liquid level ill the dislril►ution box above outlet invert tide to an overloaded or clogged SAS or cesspool ___ ✓ Liquid depth in cesspool is less than 6"hclow Invert or available volume is less than %day flow _-- _nz Required puoiping noire than 4 limes ill the last year NOT title to clogged or obstructed pipe(s). Number of times pumped ✓ Any poilion of the SAS,cesspool or privy is below lligh ground walei elevaliou. Ally poilion of cesspool or privy is within 100 Icet of a surf ace Water supply or lribulnry to it surface walet supply. _ ✓ Any pal lion of a cesspool of privy is wiltlia a toile I t►I,it public well. __ _✓ Any pollion of a cesspool o, privy is within 50 feel of a private water, supply well- _ __,eoe Any poilion of a cesspool or privy is less (hail 100 feel bill gicaler lhan 56 feel Iroril a private Willer supply Wc11 Willi oo acceptable Willer duality analysis. l`I'his sysleut passes if the,well wale►- analysis, pel for,ned al a 1)1?1' certified laboratory, for coliforn►llacleria lilt volatile organic compounds indicates that file well is Il-ee bola pyllutinll (role (ha1 taeilily alit the presence of at,►nlonia nitrogen and nilrale nitrogen is quill to Orr less Illau 5 ppul, prtivltied f 11,11 110 atliLl- Illilttl'L L'rilerla are triggered. A copy of.like analysis 1l►nSJ hL allached It► Ibis fornl.I _AL(Yes/No)'1 he System fails. I Julve delerillinetl ibill one 01,more t►fllle above fittltlre clileria exist as descitbed ill 310 CM 15.303, Illerclore the systei l (ails. Till;systerrl owner should contact like Board of , lle;dlik to delel'inille WWII will he necessary Ilk correct Ilse failure. 1�. 1.:►rge SystL,us: `1'0 1)L calisidere(I a large syslcill the sysfcrll t►)usl servc a facility with a esign flow of 10,000 gptl l0 15,000 gpd You must indicate either"yes"or"rto"to each of(lie following: (Vile following criteria apply to large systems ilk addilion Io Ilke cril is above) yes no _ the system is within 400 feet of a surface diinkil water supply file system is within 200 feel ol'a ltibillary , a surface tit inking Willer supply — _ the system►is located in a nitrogen se dive area (Illlerjin Wellhead Protection Area—IWPA)or a slapped 'Lone it of a public Water supply I 1(you llave ilnsweretl"yes" to ally title ion ill Section H the systein is considered it significant I Ill eat,or answered "Yes' ill Section)1) allove the large sleet Jlils failed. rlle ownel.of olleralor 01,40y large syStenl considered a sigsillcalll pineal Willer Seclialt f .r failed I!, let.Soclioll P slldll opgratle Ills sy41e11)irk accordance wjtl) IQ CMR 15.3()J be systep Iwnet silt . .(I contact file applopriale(egional office o(!lie Ueparllllel!l• 9 , agesof ll OPOCIAI, INSPET'11ON DORM - NOTTOR VOI..UN VARY ASSESSMENTS SUBSUR ACE SILWACC OISPOW, SYS'rCM INSPL:C`Jf'ION'rOjlm GNIr?CICC.YS7 Properly Address: 261 Ames Way Centerville,MA Owner: Kathleen Djerf Dale of Inspecliolk: June 28,2007 Check if the following have been done. You nrusl iodicale"yes"or"no"as to each of the following: Yes No Pumping inl'i,nnation was provided by the owner,occupant,or hoard of Ileallh Were any of the sysleni components pumped oiil in lbe previous two weeks ? Has the sysiclil received rlorrnal flows in tilt;previous two week period ? lave large vtiluroes of waIcr been iolrodIced to the system rcccnlly m as part oI'this inspection'? Were ifs bnlll plalls of 11kc systerll oblailled and exalj-kioetl?(If they were not available dote as N/A) ✓ _ Was the facility or dwelling inspecled for signs ol'sewage back up '? _ Was the site illspccicil fur signs of break mil `? _ Wcre all syslenr coMyloneuls, excluding Ilke SAS, located on site '? ✓ _ Were the septic lank nlimholes Uncovered, opened, aild lilt interior of file tank inspected for file condition of the baffles or lees, nlaleiial of consliuclion, dinlcnsions, depth of liquid, depth of-sludge and depth of scum'? t✓ WaS the facility owner(curl occupants if diffcrcnl Iiorn owner)provided Willi inforknaliou on the proper maintenance of subsurlace sewage disposal systems '? 'I'lle size ante location of like Soil Ahsorllliap System(SAS) on the site has been clete►mineii based on: Yes no _ l"xisting intornlalion. I'oi example, it plait al Ilse f1paril of l lealth. ✓ _ heternlineil in the field(if any of the tailnie crileria related to Pail C is al issue approxitrlalion o('distance is unacceptable)f 310 CMIt 15.302(3)(1))) ilage6 (,ftl Ot1I-IC:IAL INSI'1W11ON FORM -- NO)' !'OIZ VO1AJN`1'A11V ASSESSMCN`r'S SUBSUR ACC SI WACIi, ()151'OSAL SYS'1TIVI INSI'lecl'XON 1+OI2IYI !'A 12 I' C SYS`F-M IN O tmATION I't-nperly Atl(lress; 261 Ames Way Centerville,MA Owner. Kathleen Djerf 11111c of Inspecliou; June 28,2007 nmw c'ONPI`1'IONS ItLSID N'I1A1, Number of bedio0nls(design): Number of bedrooms(actual): ,.� OFSIGN flow based o0 310 CMIZ 15.203 (for example; 110 gpd x 11 of beclrooms): 3 3 V Number of current residents: Does residence have a garbage grinder(yes or no): Alp Is laundry on a separale sewage syslent(yes or rut): MQ [if Yes Sepal-ale inspeCuol requiiedl Laundry system inspecled(yes of 110): Seasonal use: (yes or no): AM Water tncler icadings, if available(last 2 years usage (gpd)): Sump pump(yes or no): A/O Last date of occupancy: �P CONIM]LeItCIAI.JIN1)US7•t2IA1, Type iif establishment: _ __ __ Design flow(bascel on 310 CMIt 1 S 203): Basis of design flow(sea ts/persons/stlll,elc.): Grease trap prescnl(yes or no): ----- -- — Industrial waste holding tack present (yes or no): _ Non.sanitmy waste disclialged In the`I'ilic S Sysl 1(yes or no): _ Water rnelei readings, if available: —_- Last date (!occupancy/use: O7'Itt li (describe): GXNIAtA1. INI-'ORMATION I'utitph►b 12ec0rds Sour cc ofinfi,;ivalion: Was.system puiuped as part of the inspection(yes oI-lit)): d/p 1('yes, volume ptoopcd:----galluus I low was cloanlily pumped determined?-- 12eason ✓Septic lank,tlisU-ibutioo box, soil absorption system _Single cesspool _Overflow cesspool Privy Sharcd system(yes or 110)(if yes, attach previous inspection records, if any) _Innovative/Allernulive technology. Attach a copy of the current operalion and maintenance contract(to be obtainer! from system owner) `right lank _Atlach a copy of the DUAI approval —011ter(describe): --- — Apptoxifpate age ofell components,(Mlle inslifhle(I(lf knowi))aq(t source of inlouullion: Oh IIL D! Were sewage oclots elected when arriving at the site(yes or lto):MQ 6 Page 7 oft I OVIACIAI~ INSPECTION FORM — NOT Y+OR VOr,UN`rAlly ASSESSMENTS SUBSURFACE S,WArC1 plSPOSAJ S'YS'lTM I<NSP CTIONTORM PA IV(. C SYSITM INI+ORIV A x'ION (continued) Properly Address; 261 Ames Way Centerville,MA . Owner: Kathleen Djerf Date of lnspeclion: June 28,-2007 1i011,1))NG SLWEAZ(locale on site plan) pepth below grade: —1 114� Malcrials of consliuctiow __cast iion ✓q0 PVC. other(explain): —_ _ Distance fiool piivale water supply well or sucliop line: ,cih Comments(on condition of joints, venting, evidence of leakage,e1c.): SEPTIC TAN)C:_/(locale on site plan) Depth below glade: 6F Material _melal_fibciglass-polyethylene if lank is u)elal list age: Is age auifiimed by a Certificate of Compliance(yes or no):_(attach a copy of Ceillfle;lte) - Dirriensions: S ' X 5 ' Sludge deplll PIslalice from fop of sludge to bollool of outlet lee or baffle: �t Scum tllicl:pess: Distaoce fionl lop of Scum to top of outlet lee or baffle: Distaoce from bottom of scum to bottom of outlet tee of 1)afilc: c> f low were dimensions docrnliocd: _----- Commeuls(oil puinpilig iccor I'll iendaIious, inlet and outlel Ice or battle.condition, structural inlegiily, liquid levels as relaled. to outlel invert,evidence of leakage, etc.): CRCi ASL'CRAIl'; _(locate on silo plan) 1Jep111 below grade: Material of constnlction:_ concrete—_ntctal fiberglass_ yethylene_other (e x p l a in):_____ ------ —----- ------ Dimenslons: Scum ll)ickness:_ Distance hom tot)o f sellin to lilt)of outlet fee at-halt ___ ))isfal)ce tiorri Uolforr�of scorn to buluuu of oillle ee of baffle: Dale of last pumping: — — Comments(oil putl)pinb recolurr)endatiou nlet and outlet tee of Ualtle condition, slnlctund integrity, liquid levels as related to outlet invert,evidence of age,etc.): 7 i Page 8 of I OH ICIAL INSIij�CTION I'ORM — NOT V'OR VOI JNTARV ASSMIVIENTS SUBSURFACE SEWy ('.1� 1)1S 'OSAf, $VS'I'IW INSPECIAON VORM SYS`I CIVI INFORMATION(continued) Properly Address: 261 Ames Way Centerville,MA O+�'►`'�' Kathleen Djerf Date o f Inspection: June 28,2007 TWAIT or 1101.1)ING TANK: (lank must lie pnmpecl at linne of in eclion)(locate on site plan) Depth below grade: Material of couslrnclion: txmerefe nnelal (iberbla_ _polyell►ylene otber(explain): Dimensions: - Capacity: Design Flow: _ __ gallons/clay Alarm present(yes or no) _ Alarm level:_—_ Alarm in working der(yes ol-no):__— Date of last puunping: _ Cinnmenls(condition of ularin and oat switches, etc.): I)IS'I'121111iflON 11OX: A✓ (ifpreserH nnusl he opened)(locate oil site plain) Depth of liquid. level above outlet invert: Continents(]into if box is level and dislribuliou Io oullels equal, arty evidence of solids carryover, any evidence of leakage into or out ofhox,c(c.): ) PUMI'COAMI1,It, (locale oil Sill:Ilan) 1'un'lps in woikiltg ostler(yes or no): Alarms in working order(yes or no): Colluneyts(!tole condition of pump cbaulber, colic ion o f pumps and appurlcoances, etc.): 8 Page 9 of.I I 014"ICIAL INSI)ECTION feOjIM N(Yf Cioll VOLUNTARV ASSESSMEM'S SUBSURFACID SEWAGE SYSTFIN INSIT CTION FORM SYSI FM INFORMATION (coilliolled) I'l-opedy A 261 Ames Way Centerville,MA e 1f'. Kathleen Djerf ) June 28,2007 SOIL ABSORI"I'llt"M SYSTC,NJ (SAS). (locate all site plan, ext4vajjqlk nal I-Cquired) ft*SAS not localcil explain wily: Type 2_57 leaching pits, nuflibel.: leaching chambers, 1111111bef-: LP o' slk s c'—.4 leaching ga I lei its, number: leaching Benches, 1111111bel-, Itogill: leachilig fields, 1111111br-1, Llimensiolls: ovtl I'low cesspool, 111imbef-: itilloviklive/allet,liaiivtsystellI CoInIfIcills(11olc condition of soil,signs(II'hydraulic f1diul-e, level dponding, tlai)lp Soil, coodillion ofvcgelallon' 'A CESSPOOLS; (Cesspool must he ImInpe-d as part of inspectiol ocille Ofisite plan) Ntififfiet-and coofigaink6ow. Depth—lop of litiklid to ildel nivel 1: Depili laya: T)cpIjI of Scum laytf: Difoensions of cesspool: Milief.ials pf c(IIIS11*11clioll: Indication ol'81-01111dwatel-inflow(yes of I's Col'11MICIIIS(note coll(lidoll of Soil,Sig of'4tif-aillic filiIIII.e, level of ponding,condifion 6i'vegelalion, etc.): l'Itivy; (locale on site plan) Malefials of ponsp-ticlioll: Pinlellsions: I)VVIII of m Coments(note condition of Soil,Signs ofiry level(11,11011ding, condition of Vegelalion, etc.): d""z"141111- Page 10 of I I 01-ITICIAL INSPIP-CTION FORM - N01' !?OR VOLUM Afty ASSI�SSMENTS Stj 111SURFACI SE' WAG'F' IMPOW, INSPECTION DORM SVS'UC0Yj jNFOjZ-1V!ATjON 261 Ames Way P1,011Ck-ly Address: Centerville,MA Kathleen Djerf Owner; June 28,2007 Dale of inspection: SKE'J'Clf OFSLeWACE' IMSPOSAL SYS'111 M Provide a sketch of the sewage disposal Sysitill incluiling lies to 41 least IWO permanent reference landmarks or benchmarks. Locate all wells within 100 feel. Locate where public waled supply enters lilt building. or O O 5-1 6 3q Page I I Of I I 0141CIAL INSPECTION FORM — NOT 1?()It VOLUNTARY ASSE SMENTS SUBSURFACE SI-MAG MSPONAI, sys'rjW INSPECTION FORN11 PA 10, C SYSTEM I ) . IeO 1011 ATf ON (continued) Properly Allill-ess: 261 Ames Way Centerville,MA Owner: Kathleen Djerf !)ate of June 28,2007 SITE, EXAM Slope Surface water Check cellar v*" Shallow WC11S r-'slinialed del)(11 to ground water I'Cel Adjuslal lligll ground wale" clevalio" 1.5.3,115cel Please indicate (check) all incilio(is used lo tlejejolilic the high ground water devalion: Obtained lion,systell,ticsigli I)Ialis oo record - lfcllcckctl' dale of design plan reviewed: to fir V111-Obsrived site(abutting P'-oPc'lY/0bsc'valiOo I'01c withip 150 fcct ol'SAS) Checked will, local ljoal(l ol,I jealfli-explaill: Cliecked will, local excavalols, ilislallci-s- (allacli (locill)IC111alion) Accessed USGS dalabase-explain: -m- _0 1/1._� You 11111st describe how yoo eslablislied the high groliI.Itl 1vater elevafiloik: L Li ---------- /5, 3 This report lies been prepared anti the sys tem. lqspeC(O as 0 1110 dOlo of Inspection. TOIS report 14 not 4 warranty of Oq?rPn1§q that the syplem W111(unction prQpOijy In the ft*TP- There liqve bqpq rip warranties or guarantees, e e expressed, written or Irnpill , re 1p!In 16 the pyoliprn, jhQ jnppqqpn and/or Itlis report. December 6, 2001 261 Ames Way Centerville,MA Mr. Thomas McKean Director,Barnstable Health Department Barnstable, AM Mr. McKean, This letter is to certify that the septic system at the above noted property was installed in substantial compliance with the State of Massachusetts Title V regulations and Town of Barnstable bylaws Sincerely, Tl t ello,P.E. sNoMAS mWfeELLO v C►VIL .2442 SS10 r //. I'UWN OF BARNSTABLE ��- LOCATI;ON '2 al l S 9 SEWAGE # 06 73 v VII LACE C,�`�T'F_ (� ASSESSOR'S MAP & LOT_120 235— INSTALLER'S NAME&PHONE NO. SEPTIC`TANK CAPACY C, du LEACHING FACILITY: (typ(F s �c�,aC rLe��+-TU2 (size)� 2Y XI/ Of NO.OF BEDROOMS BUILDER OR.OWNER g PERMITDATE:_- I1710 I COMPLIANCE DATE: 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 facility) Feet Furnished by a eT O © mil Se r � � 1 No. �w /30 _ Fee z v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4�z PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpprication for Mig og f *potem Construction Permit Application for a Permit to Construct( )Repair( pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Z.(/i s �U Owner's Name,Address and el.No. cen rvo Il G , , l '�obc"+ �a-4-E- Assessor's Map/Parcel , 1 _ �3 5 same Installer's ame,Address,and Tel.No. ff Designer's Naroe,Address a4d Tel.No. 5-T"r n y) .S�- -750-9'73 arras- Moaoup-13 � 8�y�ff-02Z8 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'I�pe of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures _ Design Flow gallons per day. Calculated daily flow 3 gallons. Plan Date 11 In /01 Number of sheets ` Revision Date Title Size of Septic Tank k�_ F/S'k7>?!i /0VQ I aJ_Z Type of S.A.S. Description of Soil Nature of Repairs or Alterations( nswer when applicable) OD'_0 (.(tic n(Y2:t�p ig JZ INiSTALLATiON AND CERTIFY IN %AM i Date last inspected: i,HE SYSTEM WAS INSTALLED IN $'d'�' Agreement: f.r'CORDANCE TO PLAN. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provision of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu b thi Board of I Signed Date ,7 7 v� Application Approved by 4v - Date 1 1 2 7 O Application Disapproved for the follo ing reasons Permit No. '2 Oo — 7 3 0 Date Issued `No. 1 30 f',.- `f � � } �, �� � Feeir �y A THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer: L/ 4• Yes PUBLIC HEALTH.DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppftcation for Miq,00ar *pgtem Construction Permit Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �j l� Owner's Name,Address andjeell.No. L2 Y1r Y U 1 G '�+ 1 m-"�"�" Assessor's Map/Parcel ' ! SQ me—. lnstaller'scName,Address,and Tel.No. Designer's N e,Address and Tel.No. >O e n•e_ `2 obe r S "�Nt a rye do 5_r n � Ma 0Z�`�"" -150-913 (c.X/I��y�t�-02 2 tiJ. �L a Y n• (,y� 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 376, gallons. Plan Date )I In 81 Number of sheets Revision Date 4 Title 1 ay Size of Septic Tank OZ20 ci ct, Type of S.A.S. / Description of Soil Nature of Repairs or Alterations( nswer when applicable) ew dj 4y �!1 l e ?A � •G `SLX I11A 9 ILI )'IQ 51atj .� J n a YjS Gc rDu f'Y a �K�ls . 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 provisiong-of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is by thpBoard of e lthJ�'Q o Signed Imo` v` Date Z 7 d V` Application Approved by - Date ( a 7 U Application Disapproved for the following reasons Permit No. '2 0o — 7 3 a, Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-sit gvage Djisposal System Constructed( )Repaired' , )Upgraded( ) Abandoned( )by V V )`e 0 0 -e V at S w V V l I I {-- has been construe ed in accordance with the pro si&� s o Titl'e,�5and' Dispos 1 stem Construction Permit No. a Uo I—730 dated / a o 6 Installer tl Y��v ��.e. � Designer The issu nce'o s ep, rmit shall not be, ons, ued as a guarantee that the system will function as d i e g Date •�- Inspector AMA./ � No. /?d ' 2 3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ig oaY *p5tent ongtrurtion Permit Permission is hereby ranted to Cpn�sttruct( ) ep air )Pnpgrad ( )Aban.on( ) System located D4AUKt- 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 Pe Date: ) �2 7/°-U0 1 Approved by d� TOWN OF BARNST.ABLE FC LOCATION (( U SEWAGE # apo l 7j V VILLAGE �n'�7"F ,,Vr(I� ASSESSOR'S_MAP & LOT 17� a3s INSTALLER'S NAME&PHONE N07— SEPTIC"TANK CAPACITY S LEACHING FACILITY: (ty �Pub��a of Cz rL'r#"- W (size)(3 .2J 1�l! NO. OF BEDROOMS '. BUILDER OR OWNERR(rc�--� PERMIT DATE: 11 Lz L(o i COMPLIANCE DATE: 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 facility) Feet Furnished by 15 i i� .�--140..--_.. .�'j.-•--- Fins............._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..%sQ.W..N------....OF....... N. ..! .4 ........... ApplirFafioit for Disposal Works Tonstrnrtion lbratit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at: ------------------- `�/� / f ocati �adr s-� ........ V.1 .0%.. _�L.�...... lPi �_...... ' ---------------- 00......*.....!`...... , er t�--_--•-------------•-Address Installer Address r Type of Building �9 Size Lot.Z.58 S/_.:...Sq. feet U Dwelling—No. of Bedrooms................ Garbage Expansion Attic (atj Garbage Grinder ("e) PL4 Other—Type of Building ............................ No, of persons..:._ ( ) ( )........................ Showers — Cafeteria , Q' Other fixtures ---------------------------------- _iy-----------------------------••-•-•-----•-•-•--------- W Design Flow........../Z4.....................gallons per i perlay. \. otal daily flow..........,za a...............gallons. 04 Septic Tank—Liquid'capacity,f��OO..gallons Length<6.2r..'. Width...".;;,!.a.'. Diameter________________ Depth... _... W Disposal Trench—No..................... Width.................... Total Length_ ........ ..... Total leaching area....................sq. ft. Seepage Pit No.___./............ Diameter.....5. ._..... Depth below inlet...... ... ....... Total leaching areaAZO ....sq. ft. Z Other Distribution box (4 Dosing tank ( ) aPercolation Test Results Performed by._ _-';4 Al-lU<••-... .......•...... 'Date...Ad9.tl:_.. a Test Pit No. 1...44,._......minutes per inch Depth of Test Pit...../_____.._.... Depth to ground f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a+ -•----••--------------•--•-----••••-----••••--•-•-•------•---•............:......-------.._..--•----•....----.............:............................. O Description of Soil----------- e_04_Zq------------- 3.. . C���.�Ga!"G----------T .........................�7 _ _._..__.._.._______............_......_._.............. M _._..._—________________________________•_-•_----•_____-____------.---------__.-.-.------•---------___------.---_-_____._______.----------__--_-__---------_•-_--•___---•-.._--.-.•--.--•_-________.... U Nature of Repairs or Alterations—Answer when applicable------------------------------------------..................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT= 5 of the State Sanitary 4Co —The u e Sig further agrees not to place the s stem ioperation until a Certificate of Compliance has t b ar health.Sig -•- ----...--•---------•-•--.. .....-••-----••••..••... .......... ............- / • Date - Application Approved By..... __�.. -------------- _ _ . Date Application Disapproved for th following reasons-------------•-------------------••--•--•------------------._......----------.__..___.---._..._..------•--..... _.-----•----•------------------- ---------------------------------- ---------------- _------------------------------------------- --•----------------------------------------------------- Date � � Permit No.---•-----�-•--�-................................._ Issued_--•------••---�'--�"--------�--••................ Date NO........ ...... ..............�..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF........ Applira#ion fur bispos al Works Ton'.5#rnr#iun rumit A�pli�ation is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at f cati Addy s r t No. ,/J :� 1�t�r '`� .....--, �� � ..: d ° < ---------------- . .... _..- • ---•--------------- -•---_...- --- ..........----•-----------.._...... ---------- "t er F Address /t ...............)T � -------..__........ ------ ,4 ... 14 Installer Address d Type of Building Size Lot__l� `_ _ ...Sq. feet U Dwelling—No. of Bedrooms_________________a.....................Expansion Attic (-V# Garbage Grinder (Af) a Other—T e of Building ______________ No. of persons............................ Showers ( ) — Cafeteria Otherfixtures ; '- ---------------------------------------------------Z - ..............gallons. WSeptic Tank—Liquid capacity,l.400_gallons Lengthy.25.*."__ Width__5-el.a Diameter................Depth__ x Disposal Trench—No..................... Width.................... Total,,Length.................... Total leaching area_...................sq. ft. Seepage Pit No ___ ___________ Diameter '..__.__._. Depth below inlet___._6..._..._. Total leaching area_a2.Q�._sq. ft. Z Other Distribution box (Iv}' Dosing tank ( ) 14 Percolation Test Results Performed by-__. °___....C' 711etL` .��'______________ Date.../V.<-_ttt....ak.�,. - ,Test Pit No. 1...�*.__+,•__-__minutes per inch Depth of Test Pit_____ ! ...... Depth to ground water..-ACY.AJ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................... Pd f _ "" Descrtpt>on of Soil --- "' -- 1. _. _._ ��.••-•-• !!Z / 't !' ------••-•-•-•--•-•---•-----•-•• .,..---- -•••---- ---...•. •----••- W VNature of Repairs or Alterations—Answer when applicable............................................................................................... ...-----•----------------------------------•--•-------------••-•-•-------------•-----.......---•-------..__.....--•-------------------------•---•------•--•-----..._._..---------------------•-•--••-••. Agreement: 1_411 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT.:" 5 of the State Sanitardhas o —The u r 4ignfurther agrees not to place the system ioperation until a Certificate of Complianc sued y t ' alth. t' Si ---•------• ••------ •.......--••-•-•----- _- .......... .....__ DApplication Approved By.._.... :_ --..._ , Date ollowingreasons---------------------••-•------------•------------------------------------------------------•••-•-----......... _ Application Disapproved for MA...-...........................••_•_..__....-.--•-..--••--_._......••-•--•----•-•-•----••----•-..............................-----------•-••--••---•••-•-•------------••••--•••-------••••-•--...•-•--- Date PermitNo...........`-��-..---3-............................._._.. Issued.............. ._................. Date COMMONWEALTH OF MASSACHUSETTS OARD O HEALT , t Trrtifirate laf MaanlrltFanrr THIS IS TO CERTIFY l Vhe InuividaI Sewage Disposal System constructed ( or Repaired ( ) '^ by--•••---•-------•---•-------•-----------•---•-----•-------------rw------- -�T"'�--- ______ ____-- -•-------•-•_____________________•--•---•-----•------•-- I st / �^ n at................ +.. ._ l•�-•.•••r•' ._,� ..t.............,, a a�--------------------- - -----•-•----______----•--•- -----------•-•------------- has been installed in accordance with the provisions of TITLP; -->>`' of The State Sanitary Code,,as described in the application for Disposal Works Construction Permit No._-_.____17`?�- .______.___.______. dated----- . '_-_ _.................... THE ISSUANCE OF THIS .CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WtL FUNCTION SATISFACTORY. r DATE._...------• .................... `? Inspector. ................................................... THE COMMONWEALTH OF MASSACHUSETTS R' S: BOARD F HEAVT l.C%L....."'.'.............OF..... ................................................... ,,.,.. No......................... FEE.. . ....... Disposji, rkil %.syndion rranit Permission is eby granted__.______ ''" ..... ................____ • ••• ................................... to Construct ( or Repp ) an Individual Sew ge isposal Sy at No........................ ........ -------- ---- Street x as shown on the application for Disposal Works Construction Permit No......3Y3._._ Dated_..___4_".. ...........I'—I...... Board of Health DATE.................•- -_ - FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 36 0 3V,3 LOCATION SEWAGE PERMIT NO. VILLAGE INSTA.LLER'S NAME i ADDRESS a U I l D E R OR OWNER J�c/C 1,2-e14 A? DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i � I i r � 5 a A - 1/6, g � � ;Q'AC L Ivi0R'kA-Y - .tNSPeCTOR, 3• k Lb F•36v 33 + t :E.X 15T. 3 SLJLS'C /L : 5A.MV0 - AN S TONNES. r � i � � • ro` 5 EPT 1C� 7ESt �. . .. ' RF_SERVE -'A N K HOLE o L�LEV. $ DiST. 13ox Ibf� Ul s' NO LJPTE/:k -ENC0L.II LEACH , prt ' "T•dwN L )AT E R AVA !LA B E. E '41^-f A4 U./t// F20NT. 'Si DE —ZQ T24T� i +• , - k r Y ^4 �. `r-�3 F. D 240MS'r , � 5EP"7-/C 5 Y5 TAM CONS 7-12'UC-7/O�/ #' SHA LL CONF02M'..TO MASS • -- }} i ENV/2o�1/MG-ivTAL COO,'- 7/7 pES�G!v FL+OuJ. c�AZ—IC?A f EX l S'T!lV Cr 'E V"/5 .7 /'- 7 7 C3191 z� f, L G 4 C.:;ry., 2.4 -TOP ;QF Al�AL7-1-1 TZ GGULA T/On/S Q�!�'G-D _ . O O _ .�r,.......>,--- f rEa STOit%� MAA1140LE Cat/E/a 7"O k,TE�lD ?O, . - IRCl2✓/OC/S G.O f 0F 'GIZA F/L' T2AT/ti/°b '�• .ST ( JOX �I, Z/"N//DE OC/E,e 3:.w41w1 A• ATF.Z > _ `/�vE M/,v 'p �' ry'�_T 4'r.D/d e /O Leg Gs;�• C' ` F 1/D:•'M/N .. • P/r Dar; /4" �4-iFOOT M/iv ./�rTtfi _✓_ I C o A �.. M,ti �'' a00 ;V SHE0 13 /A/✓f.2 T t I C,4'iFAG•/ 7-Y _ ELE V.- 'A��?12 O Un/O t (M/A.7ZZ w H T) /ti i/E2T v: i.v vE<zr .ND ! L o A 7'i 0il/ 6i9 R"N _7 A.0 — 0 .1 � _IrI N Sit of M SEAT 1C=: TAN L7/ 7-lZ/BUT/ON 80X ' OuT/-ETS Ld--AGA!1NG A/T' /=O P,ONALDi�Er�/F4TZCED GOAJCTZGT6 iZ Ark Fi R GIFFORE3 L Cn/G'2ct TE -S T2GA/G77/ 3000 , M/n/. .. � - - - 15Yt C/�Octl�� � � T�?f4c�le Cad?' S�f0STE��O�.' �Y-/o LOADIAAG r �� '!t t'✓mot r' A/O T TO B E L 0;:7A Y A 0 Al 0Ua" 1AC2M ilrCERTIFY TNE' �.XjSTiNG �'t UNOAT/D>v �,S _ / ter Lo��/,vim /� v's�z ! LDCATION IS CORRECT AS 5#0tJN ANp a ��r IT 0065 C'0.lYI pty W iTk TF0� 5E? C�w:i EOR 1R BACK off. cW. JR �� .( ` ---- ------ _--_ REC UIREMEPJ S tJF TNF TOWN 04* U , � I 'Q to S A R N S T A C L E r ll����s r ``��,` F --- -- ------- - -- - _r -- T°� v is r3AP 'N y 'pQ �. Tor' �Ni� 1 AVIES �E � - 4 .o �tST• 13� �jA51 y 37. 73 3 • 5 6 W &N0 S 1 t 5 E XI T%- MAP 170 • IJ oor� 37.90 — — — — - - � � i 8, t5 �.� � pRrtc.E� TA 235 / v P TA,,-3 3 5.3 LOCUS: CALCULATIONS: SIDEWALL: (2)(0.833)(34.25)=57.00 S.F. 20 Ft c.E ,f 7E�G �� C7"� (2)(0.800)(11)= 18.33 S.F. p _ -rEs , EE • I 5, �6 y`r I I 1 OTTOM: l I (11)(34.25)= 376.75 S.F. �. 2 I EST � �E!Z C (Z A 7 = N � `^.r: � (� (� TOTAL AREA =452.08 S.F. 1 p 6 =_ T}}- 3 4125 �" PERC RATE L 2 M i n1 j i nl c k 5 A N Y R 3�I 3 8•o USE 0.74 GPD/S.F N� �oAh y PE�c EST C o r j j)vc,TE D f`` 33 o\ i L�Al ', I o YtZ O t o ( c 1 ' 2 0 0 ( \ o �\Q TOTAL FLOW=334 GP ' Q 2� s a No � �g _ ot: �s9cy i IZtA1J CC- L ( A o�� THOINAO 2 E(,=3 b,l b Z•5 `j 2"1 tdl RC 5 aN� _.. ENGINEER: c►vr< H 4 C I (lo W I T N E SSE 1� (j �/ o �_- (, N THOMAS MARCELL . M.24421 35 BRETWOOD LA q�• R�� ' I 1 O L E e µ C- CO h1 ►J E L t- , CENTERV - ILLE, MA NAL i �0 I �� { l o l R (508)428-0228 C Sp.rJQ b -— P�Pr� I [LLZ = 41 •0 "3 o VJAi�--� 0�5ci2\�7 (� [ 2c SEPTIC SYSTEM REPAIR PLAN t10 FOR zco 1 aMts wAy .y •. r T3tNG1'' - CENTER v t t..l-E, M.,A IV O T C s A 1 3 To p �n1 ► MAP 1 '1 O PARCEL 2 35 <e J QQ� v • �IrV�V V�� r! �� 1 /'�/V K Q ( U�� E•X� 5 1� N�i J � 17 reA �EZS w a OWNER: Ro(3EKT PRAT r 2` SASS &4A l,L JSC J v �' t 261 AKES WAy �1-� CENTc Q 'Jr LL C JA A 5 J(p,,�, tic ( SAS) s C A SCALL in fleet = 3 )q.C_o nJG SI VVA 0 20 Im r>o 1 inch = 30feet I