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HomeMy WebLinkAbout0331 AMES WAY - Health 331 AMES WAY, CENTERVILLE A= 170.229 lll! �q UPC 12543 Mo R HASTINGS, MN i �. C' V " i i s a I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 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. General Information (� on the computer, � I use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return key. Name of Inspector B & B Excavation, Inc. Q Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 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 12-3-10 - � Inspector's Signature Date :�s 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. (� J IV 1 6 t5ins•09/08 Title 5 Official Inspection Form:Subsurface S age Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 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: 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-09/08 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 �M 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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 FIND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more tha n 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 FIND (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•09/08 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 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 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 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: At time of inspection septic system appears to be in good woking order,however the home does have a garbage grinder and the system is not design for.B.O.H requires removal of grinder. 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 'h day flow t5ins•09/08 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 331 Ames Way M Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. Citylrown 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 P pp y p 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-09/08 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 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. Cityfrown 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): 330 !Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage n/a 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ti Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes,.volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 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: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'6"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leaka eor blockage 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: 5.2x5.2x8.5 Sludge depth: 6" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 1211/10 page. Cityrrown 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 30" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good shape concrete baffle present on inlet and p.v.c. tee on outlet, no sign of back up,tank appears to be struturaly sound Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. City/Town 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: 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•09/08 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 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. Citylrown 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 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be structuraly sound no sign of carry over or -101 backup.Recomend installing riser to bring cover within 6"of grade. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): At time of inspection leaching appeared to be in good shape ,no sign of staing or hydraulic failure.Chambers had no standing water(was dry).Recomend installing riser to bring cover within 6'of grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. City/Town 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.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09108 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 r� 331 Ames Wa M y Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. Cityrrown 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 C "REAR O F Al 52' 132= 20' �3 25 ' C2 _ z4 , G3 - Z9 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 331 Ames Way Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 page. City/Town 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: >12feet 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: 12-21-98 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: Recorded paper work on file with b.o.h.(12-21-98)top of ground eiv.45. observed water elv 30 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 331 Ames Way M Property Address Robert Mellville Owner Owner's Name information is required for every Centerville MA 02632 12/1/10 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth Of Massachusetts Executive Office Of Environmental Affairs Department Of Environmental Protection TITLE 5 Official Inspection Form -Not For Voluntary Assessments Subsurface Sewage Disposal System Form Part A Certification -Property Address: 331*Ames Way Centerville Ma.02632 Owners Name:Jennifer L.Just Owners Address:331 Ames Way Centerville Ma.02632 Date of Inspection:8/24/2006 Name of Inspector(please print)Sean M.Jones Company Name: S.M.Jones Title V Septic Inspection Mailing Address: 74 Beldan Ln. Centerville Ma.02632 Telephone Number:508-778-4597 CERTIFICATION STATEMENT I certify that I have personally,inspected the sewage disposal system at this address and that the information reported below is true,accurate and,complete as of the time of 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: X Passes Conditionally,Passes Need`s further evaluation by the Local Approving Authority Fails Inspectors Signature Date: ,goo f,, 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. Notes and, Comments: ; 7 97 ****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. Page 1 J OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cow um) Property Address:331 Ames Way Centerville Ma.02632 Owner: Jennifer L.Just Date of Inspection: 8/24/2006 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.System Conditionally Passes:N/A 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. Answer yes,no or not determined(Y,N,ND)in the_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 the 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 structurally sound,not leaking and if a Certificate of Compliance Indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or Obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with Approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(S).The system will Pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 C.Further Evaluation is required by the Board of Health: N/A 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 31OCMR 15.303(1)(b)that the System functioning in a manner that protects the public health,safety and the environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Surface water supplyor 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 less than 100 feet but 50 feet or more from a Private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform Bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 provided that-no other P g g q PPS Failure criteria are triggered.A copy of the analysis must be attached to this form. 3.Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. T X Any portion of cesspool or privy is within Zone 1 of a public well. X Any portion of cesspool or privy is within 50 feet of a private water supply well. X Any portion of 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: 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 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 CM15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X_ _ Were all system components,excluding SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No X _ Existing information.For example,a plan at the Board of Health. X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance Is unacceptable)[310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 FLOW CONDITIONS RESIDENTIAL 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):_330 GPD_ Number of current residents:-2- Does residence have a garbage grinder(yes or no)_no Is laundry on a separate sewage system(yes or no):_no [if yes separate report required] Laundry system inspected(yes or no):_n/a Seasonal use:(yes or no) no Water meter readings,if available(last 2 years usage(gpd): Sump pump(yes or no): no Last date of occupancy/use: current COMMERCIAL/INDUSTRIAL:N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping records Source of information: owner Was system pumped as part of the inspection(yes or no): no If yes,volume pumped: gallons--How was this quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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 the system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,Tank. 1979--D-box+S.A.S 1999 Were sewerage odors detected when arriving at the site(yes or no): No �L OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction: cast iron_X_40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Joints were in good condition,no sign of leakage. SEPTIC TANK: X_(locate on site plan) Depth below grade:_13" Material of construction:_X_concrete metal fiberglass_polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8`6"X5`6"X4`10"= 1000 Gallons Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: 2.5` Scum thickness: 1" 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.opened covers and took measurements 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 does not need to be cleaned at this time,but should be cleaned every 2 years.Liquid level was at bottom of outlet invert.Tank was not leaking.Tees and baffles were intact and in good condition. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglasspolyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of Leakage into or out of box,etc.): D-Box was level and in good condition.There were no solids carryover.D-Box was not leaking at time of inspection. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 SOIL ABSORPTION SYSTEM(SAS)_X_(locate on site plan,excavation not required) If SAS not located explain why: Type Leaching pits.Number: X Leaching chambers,number:- 2-Leaching galleries,number: Leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternitave system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Vegetation was normal,soil was dry.There were no signs of hydraulic failure.At time of inspection leach chambers had 0 inches of standing water. CESSPOOLS: N/A (cesspools must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 5+_feet Please indicate(check)methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: High groundwater elevation was determined by accessing The Town of Barnstable Groundwater Contour Map. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:331 Ames Way Centerville Ma.02632 Owner:Jennifer L.Just Date of Inspection: 8/24/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building C O REAR OF HOUSE 0 B 3 4 DECK A � 1 C� 2 TANK D-BOX S.A.S. A-1=10' 8-3=16' B-4=20' B-1=21' C-3=27' C-4=29' A-2=12' B-2=26' J 1� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION / 70 �e • TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner's Name: STEPHANIE SANTOLUCITO Owner's Address: III CORPORATION RD.HYANNIS Date of Inspection: 8/6/01 Name of Inspector: (please print); JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: PO:BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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: X Passes _ Conditionally Passes _ Needs Fu a Evaluation by the Local Approving Authority Fails Inspector's Signature: �' Date: 8/6/01 The system inspector shall submit 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. Notes and Comments ;; SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.`hls inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 incnPrtinn Fnrm 6/1 5/W100 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM. 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old'is available. ND explain: n/a { n/a 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 _ obstructiore is removed _ distribution'box is leveled or replaced ND explain: n/a n/a 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 _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this'form. 3. Other: n/a ye s t Z Page 4 of I I t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding.of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy,is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma (Yes/No)The system fails. 1 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, now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 Inrgt system has failed.The owner or operator of any large system conaiclered 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. d Page 5 of I I } OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ 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 `' X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems' The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S I Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: I Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO {' Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203.):_n/agpd • Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons`--How was quantity pumped determined?n/a Reason for pumping: n/a ' TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1998 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 1" 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: n/a 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE SYSTEM. GREASE TRAP:_(locate on site plan), Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 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(expiain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day s Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): DISTRIBUTION BOX IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a c Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO RMATION(continued) Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 SOIL ABSORPTION SYSTEM(SAS): X,(locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a Jeaching pits, number: n/a 500 GALLON LEACHING leaching chambers, number:' 2 CHAMBERS leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a Teaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system n/a Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) t 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 or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 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 n Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. v P, o � . o SAL, as RP a� C in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 331 AMES WAY CENTERVILLE,MA 02632 Owner: STEPHANIE SANTOLUCITO Date of Inspection: 8/6/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-if checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) - NO Checked with local Board of Health-explain: n/a -` NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET s COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 W1LLIAM F.VELD Bob Frederick �DY CORE Governor ,/ Secretary ARGEO PAUL CELLUCCI DAVID® TRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F A/ ��© Com ssioner PART A CERTIFICATION TO 'o ' 999 Property Address: 331. Ames Way, Centerville , MA Address of Owner: sa. Date of Inspection: /` 19"q I (If different) Name of Inspector: Wm E Robinson Sr Sop 1 I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Servi c Mailing Address: PO Box 1 089 iCent-pr yi 1 1 - , MA 02632 Telephone Numbers 5 0 8 77 S_R -7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: l� Passes _ Conditionally.Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 11 Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the systLsm is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A)^ M PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 31.0 CMR 15.303. Any failure criteria not evaluated are indicated below. ENTS: Bl S STEM 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. Indicat yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/twww.magnet.state.ma.usldep e'j Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 331 Ames Way, Centerville , MA Owner: Bob Fredericks Date of Inspection: / f F-q P B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURT iER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 t � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 331 Ames Way, Centerville , MA Owner: Bob Fredericks Date of Inspection: /—/9-9 1 D] S STEM FAILS: You m st indicate ei;?,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.• Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARG SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safety and the environment because one or more of the following conditions exist: 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 _I the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone 11 of a public water supply well) Ther operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program req of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 4 ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST y L Property Address: 331 Ames Way, Centerville , MA Owner: Bob Fredericks Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes/ No _✓ _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location.of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:331 Ames Way,Centerville., MA t Owner: Bob Fredericks Date of Inspection: /-/?- FLOW CONDITIONS RESIDENTIAL: Design flow:,p.d./bedroorn for S.A.S. Number of bedrooms: .3 Number of current residents:,, Garbage grinder (yes or no):,a/0 Laundry connected to system (yes or no):�ti J Seasonal use (yes or no):-/--.0 1998 20, 000 gal. (6 mos) Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):_,&51 199 7 51, 000 gal. 1996 51 , 000 gal Last date of occupancy: g Gj COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: .Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: / 1:5� 4 System pumped as part of inspection: (yes or no)L d If yes, volume pumped: Gallons Reason for pumping: TYPE OF 4STEM ' Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of al l components, date installed (if known) and source of information: ;`)off 1 ;Ir f—' "/ 0� Sewage odors detected when arriving at the site: (yes or no) t v (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION (continued) Property Address: 331 Ames Way, Centerville , MA Owner: Bob Fredericks Date of Inspection: BUI ING SEWER: (Local on site plan) Depth low grade: Materia of construction: _cast iron _40 PVC_other (explain) Distanc from private water supply well or suction line Diamet r Comm nts: ondition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: ) (locate on site plan) Depth below grader_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: °E Sludge depth: �' ) Distance from top of sludge to bottom of outlet tee or baffle: d-IL Scum thickness: 0 .& ) Distance from top of scum to top of outlet tee or baffle:_ L , Distance from bottom of scum to bottom o outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet ees o�affles, depth of liquid le el in relation to outlet invert, structural integrity, evi ence of leakage, etc.) --� e4� l, , 's d t 't "' ✓ „ S GRE SE TRAP: (local on site plan) Dept below grade: Mat rial of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dim sions: Scum ickness: Distaric 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 I st pumping: Commen s: (recom ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri , evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 331 Ames Way, Centerville , MA Owner: Bob Fredericks Date of Inspection: 1_13C'_9 1� TI HT OR'HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota on site plan) Depth low grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dime sions: Cap it'y gallons Desi flow: gallons/day Alar level: Alarm in working order_Yes; _ No Date f previous pumping: Com ents: (con ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:V (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of lid rtyover, evidence of leakage into or out of box, etc.) J PUMP CHAMBER: (locate on site plan) Pumps n working order: (Yes or No) Alarms in working order (Yes or No) Comm nts: (note ondition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 331 Ames Way, Centerville , MA Owner: Bob Fredericks Date of Inspection: )—/d- 7 SOIL ABSORPTION SYSTEM (SAS): 4/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:. leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of h draulic failure, level of ppnding, conditio of vegetation, etc.) C SPOOLS: _ do to on site plan) Num r and configuration: Depth op of liquid to inlet invert: Depth f solids layer: Depth f scum layer: Dimensi ns of cesspool: Material of construction: Indicatio of groundwater: inflow (cesspool must be pumped as part of inspection) Commen s: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI (locat on site plan) Materia s of construction: Dimensions: Depth if solids• Comm ts: (note condition,of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 331 Ames Way, Centerville , MA Owner: Bob F edericks Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) e i oz d 1 i �J J/ c_ i `lid i (revised 04/25/97) Page 9 of 10 r . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 331 Ames Way, Centerville , MA Owner: Bob Fredericks Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data } Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 1 (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE LOCATION _� J SEWAGE # VILLAGE ( :.-A+ ASSESSOR'S MAP& LOT��.l�j INSTALLER'S NAME&PHONE NO. '-7 7;j ,'?74 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) .2 Cl"+W,beS (size) NO. OF BEDROOMS J BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 331 i I i f+ So3No. ,1 Fee��_ � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZppYicatiou for &-4po!5al *p5tem Cou.5truction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 331 Ames Way, Center 0vinr�Name,Address and Tel.No-Bob Fredericks Assessor's Map/Parcel 331 Ames Way Centerville , MA I ler's e, dd ess,and Tel.No. Designer's Name,Address and Tel.No. m. :" l�o�inson Septic Service P.O . Box 1089 Centprvillp , MA Type of Building: Dwelling No.of Bedrooms 2/3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand, Nature of Repairs or Alterations(Answer when applicable) D—box and. 2 stonepacked leach chambers . ZS7()D Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued_by this B d of Health. i Signed �'�✓ �d ✓� Date v� Application Approved by Date Application Disapproved for the following reasons Permit No.���(��S Date Issued No. L/ O.3 ��` � ! � ���� � Fee! 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppricatiou for �Mfgpogar *p.5tem (fougtruction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 331 Ames Way, Center 1 Name,Address and Tel.No.,Bob Fredericks \ Assessor'sMap/Paz (3..'31 Ames Way cel Centerville, MA Instal.r's g me,.,Qdodn,n d T l.N e pt i c Service Designer's Name,Address and Tel.No. WP.O. BOX 1089 Cpntprvillp . Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) D—box and 2 stonepacked. leach. chambers . gy)i U, SIQ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Bward of Health. Signed ff Date 7 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS Fredericks BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO�ERTIFYIia the On-site�$ewa a Dis osal System Constructed( )Repaired ( X)Upgraded( ) Abandoned( )by iJ . o�inson epic service at 331 Ames Way, Centerville , MA has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. C/g- i'D 3 dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the sys em will function as designed. Date Inspector -- ----------------------------- — No. O O3 Fee $50 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Fredericks i5po5ar *pgtem Cougtruction Permit Permission is hereby granted to Construct( )Repair( - Upgrade( )Abandon( ) Systemlocatedat 331 Ames Way, Centerville , MA , 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 ermit. Date: '2— Z 7 Ir6 Approved by a' 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, William E. Robinson, Sr ,hereby certify that the application for disposal works construction permit signed by me dated � J! concerning the property located at 331 Ames Way, Centerville, MA meets all of the following criteria: * here are no wetlands within 100 feet of the proposed leaching facility. * here are no private wells within 150 feet of the proposed septic system. * ere is no increase in flow and/or change in use proposed. *I Aere are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) _ SIGNED:_ �/ l DATE I �1 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). r _ JV NU y e � I i I L G .-r 3 d TOWN OF BARNSTABLE % LtCr►%'[UN 3S I A 0'V_5 kJJ_A Y SEWAGE # I "goo VILLAGE 00-. "f' ASSESSOR'S MAP& LOT f 10 • "1.tP INSTALLER'S NAME&PHONE NO.W ' ttbi Sooi 7 .0 _ SEPTIC TANK CAPACITY -/COO LEACHING FACEL=: (type). C1�6e.5 (size) - �00 t NO.OF BEDROOMS BUILDER OR OWNER Fare 1p d' e t5 PERMIT DATE: P 2/'�I a- 9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 331 A 6 10 CO, 'A T ION S E w ACE PERMIT NO. 9 YI L AC LA I N S T A LL as NAME a ADDRESS • U I L E R OWNER d DATE PERMIT ISSUED ={ �y DATE COMPLIANCE ISSUED - r ,2'10 No..79... -�/-- f Fizz.'.........................._ THE COMMONWEALTH ZJ'F-MASSACHUSETTS BOAR® OF HEALTH . .. ..:Y�..............0 F....... �J....�..��---..... ............. ......_. Appliration for Riipviial Works Tnnitrnrtiun Frrmit Application is hereby made for a Permit to Construct ( Repair ( ) an Individual Sewage Disposal Syst at- fA� e .......- ............... ................1111le ........... yL ation- e s o 'A W Address Owner C Installer Address Type of Building Size Lo.�®00.....Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder y l' , '4 Other—Type T e of Building No. of persons............................ Showers ( ) — Cafeteria ( ) P� YP g aOther fixtur s ...................................................... W g ._ __Design Flow.........�- --------..........gallons per person per dAy. Total lyflow-_---_ _l_�._n_.s..P4 Septic Tank—Liquid ca acit < © gallons Len th4 _% -.__. Width................ Diameter................ Depth.... . W Disposal Trench—No. .................... Width.................... Total Length.._..._.....o...... Total leaching area....................sq. ft. x Seepage Pit No-------/----------- Diameter........._..... Depth below inlet................. Total leaching area�Q.j....sq. ft. Z Other Distribution box (�) Dosing tank )0 Percolation Test Results Performed by... a-..........-- e •._-------_ Date._____. / _. ,...1 Test Pit No. 1....Z..._..minutes per inch Depth of Test Pit..... ............ Depth to ground water. ._ .___._ e Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .. :/- Description of Soil_._..._.. ... ----... ......----•---'s- ._.�--------------------------••-- - - ------ U ---••-•-------•---------•••-----------•-•••------------•-------•-••-----------••---•-•---------------------•...--•--------••-----------•----........•••-•----------••----------•-----•--••--•-•---•----- W ...............---...................................................................................................................................................................................... UNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h*bensued by the f health. S" - . ---••--••------• Date Application Approved BY--- - --- .......k........................ ../,/).. 2.y`.7�....... Date Application Disapproved for the following reasons:................................................................................................................ ----------------------- .---------------------------------- •---------------------------- •---- ------------------•---------------------------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date i No....... -....!_. .. Fxs............._............_ THE COMMONWEALTH OF' MASSACHUSETTS BOARD OF HEALT k. .7..............OF...... .rrJ...:�..�aG.........�------................... Appliration for DhipmFal Works Tnnstrurtion Verntit Application is hereby made for a Permit to Construct (�4 Repair ( ) an Individual Sewage Disposal syst at: yi+ . 1//Ile ....................... •- ..-•...- .............. ...................r Location- ress / or t No. .......•- ...... -........................................ ....ate. •-----............ Owner 4.......................r............................ Installer Address d a .........................© SfType of Building Size Lot/ q. pee Dwelling—No. of Bedrooms.___..__...•....•.................•..._.....Expansion Attic A, Ga bage Grin (lder /50 p., Other—Type of Building ............................ No. of persons.... ............. .....__.. Shvtns — Cafeteria ( ) PaOther fixtur s ............................................................. = ------- --- -- ------- ------ d ' W Design Flow________ ...... ...........gallons per perso per T � i ily,flow..........................3XAt._g�llgns. WSeptic Tank—Liquid'capacityhd�gallons Length ., � Wldth. Diameter________________ Depth................ x Disposal Trench—No.-------------------- Width_................. +1otal Length............ Total leaching area....................sq. ft. Seepage Pit No-------�........... Diameter.....i___........ De th below inlet................ Total leaching area.0R...D.t....sq. ft. Z Other Distribution box v ) Dosing tank cy)0 aPercolation Test Results Performed by ...... ....................... Date_e/zj� p.� G ,.a Test Pit No. 1.... ......minutes per inch Depth of Test Pit.... ............ Depth to ground water. _ _..___.. 1� Test Pit No. 2---- y_____..n n s per inch Depth of Test Pit.................... Depth to ground water........................ ' = ------------ - --- --•--•.------- 0 Description of Soil.. '-�' � 161 �_- S .c L---..5 ��..�...------•--•-----=---•--------------•---•----- ----- ------------------ W •••-••••••••-•---•----------••••-•••••••-•-•-••-•••••---•--•-------•-•--•••••-•••••••••-•--••••--•••----•••--•-•-----•--••-------••--•---•--••--•-••---------•--•-------••----•••-----------------•---•- UNature 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 TITI.L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the ardq f health. Date,_ Application Approved BY . •--'----- / '� �J/ ----- • Date Application Disapproved for the following reasons: ---------•-----------•---------•----------------•--------------•----------------••------•........._ f Date >' PermitNo.....................: ................................ Issued....................................................... Date f ` THE COMMONWEALTH OF MASSACHUSETTS BOARD ;OE HEALT ........- OF ... .................... ...................... (Inrtifirate of ToutpliFatta If IS T � CERTIFY, That the Individual Sewage Disposal System cobstructed ( or Repairedby... ..__ ..e....................... ......•• ••. •. ........................................... taller, %, ` at----nt . ---•• G�• ---•--may ---•-•- . ---------- ----------- --------------------------------•-- has been installed in accordance with the prow ons of TT F o T e State Sanitary Co e�.as es.c�ib n the application for Disposal Works Construction Permit No.__., & � .._... dated-......Ille �%+ �� P ---- •••-•• he THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A.GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Inspecto t DATE... f. - !-2.........................--.:_..� ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT 7� No.. � ........... ..... .........OF.......... FEE................. .�....� utopos or Tonntrnrtion Virrmit Permission 15 h eb ranted_______ Y g ---------- •--••• •••••-..... . ... ----------------- to Constryfizt or Repair ( Indivi ual a Disposal System Street q� r� �/ 7 C/ PP P 1.. . ......-----•..._.... as shown on the application for Disposal Works Construction. . mrt ��d.-____. .- F Board of Health DATE....- ,�='Z—.Z�-------------------------------------------------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERSs. 77 .7u ,J �F•r ���r. z` e%"' �`r. r ! �3�4 /�� ,.3, G��,i 7- /C t/-�' T ! N w_ __._ _. - r/a i" r?V .d' ��✓4' T 17 t .30 o 5) 1 '% t7 , .�' "/�.�'=t..�'.:s F/�/ Y .� 'a N, 'Lam' •�v' ?'./�t.? Cry .CJ. As 21 11)"7 ZI 77 QO ,`�� .� �i 2,9 c-,7 ' roc is 42 Icy- lip L CAS 11 ! 1 FRANK r'.1 FRANK 9; p CONERY � COnER1/ cn Na 6573 © n ; .Q No. silt O ISTIE 7-7 NAL PLAN OF LAND Ce'v regvn J. 'f- MASS. OWNED BY b N-' FRANK CONERY 5 TRENTON ST. p HYANNIS, MASS. 02601 q� q� RCGIGTILFWD ENG{MEER a LAt4o SURVEYOR \ �\\� SCALE 1 IN FT. /0 /6, 7G