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HomeMy WebLinkAbout0381 AMES WAY - Health 381 Ames Way Centerville A= 170 223 S M E A D No. H163OR UPC 10259 smead.com • Made in USA d I r Commonwealth of Massachusetts �� , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 381 Ames Way, Centerville ✓ r.� Property Address , Arthur& Rosemary Ristino 14 Hardy Lane Owner Owner's Namea information is :: required for every Hampton Falls NH 03844 6/25/2018 r.:• . page. City/Town State Zip Code Date of Inspection i- 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 A. General Information filling out forms S�-{�' �31 S ' � on the computer, use only the tab 1. Inspector: key to move your cursor-do not Jeffrey M. Wall use the return Name of Inspector key. Wall Septic Service r� Company Name P.O. Box 771 Company Address Harwichport Ma 02646 + City/Town State Zip Code 508 432 4908 673 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 nspe o' ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CM 381 Ames Way, Centerville Property Address Arthur& Rosemjary Ristino 14 Hardy Lane Owner Owner's Name ^ information is Ham ton Falls NH 03844 6/25/2018 required for every �. page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: M 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: One or more system components as described in the"Conditional Pass" section need to be eplaced or repaired. The system, upon completion of the replacement or repair, as approved by th card of Health, will pass. Check the b for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," ple a explain. The septic tank is met nd over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substan infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank I placed with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection I i is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less tha 0 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Ames Way, Centerville Property Address Arthur& Rosemary Ristino 14 Hardy Lane Owner Owner's Name --"-- information is required for every Hampton ton Falls NH 03844 _ 6/25/2018____,_,__ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ump Chamber pumps/alarms not operational. System will pass with Board of Health approval if ps/alarms are repaired. B) Systbo Conditionally Passes (cont.): ❑ Observati of sewage backup or break out or high static water level in the distribution box due to broken or �structed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspectio ' (with approval of Board of Health): ❑ broken pipe are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is rem ved ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leve or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year ue to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board o ealth): ❑ broken pipe(s) are replaced ❑ Y ❑ ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ND (Explain below): artheIF at,ie"-,is-Regi*fped tbe-Board.-of-Hea4thi,—-- ❑ Conditio ist which require further evaluation by the Board of Health in order to determine if the system is fai go protect public health, safety or the environment. 1. System will pass unman less d of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not oning 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 arsh t51ns.doc•rev,6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w� 381 Ames Way, Centerville Property Address Arthur& Rosemary Ristino 14 Ha__rdy Lane Owner Owner's Name �- information is required for every Hampton ton Falls NH 03844 6/25/2018 ___ — _ page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) System will fail unless the Board of Health (and Public Water Supplier, if any) det ines that the system is functioning in a manner that protects the public health, safety d environment: El The sys m has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a s Mace water supply or tributary to a surface water supply. ❑ The system h _ a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El The system has a s ptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water suppl ell**. Method used to determine distance. **This system passes if the well water analysis, rformed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure crl is are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ 2/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ d Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Eg/"� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 99 p ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow 15ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Ames Way, Centerville Property Address -- Arthur& Rosemary R_istino 14 Hardy Lane Owner Owner's Name -- — --- --_. information is required for every Hampton Falls __ NH 03844 _ 6/25/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 2/1/,/ 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. ❑ C qN1/* Any portion of cesspool or privy is within 100 feet of a surface water supply or �f tributary to a surface water supply. ElL"J �/� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L!Q N/�Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 2 /O�Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. �., esign flow of 10,000 gpd to 15,000 gpd. For large tems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in n D. Yes No nM, ❑ ❑ the system s irk in400 feet of a surface drinking water supply "L. ❑ ❑ the system is within 200 rdetgf a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen`t;,egiitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a pb'blyc water supply well If you have answered "yes" to any question in Section E the system is cj4ered a significant threat, or answered "yes" in Section D above the large system has failed. The owner ,br erator of any large system considered a significant threat under Section E or failed under Section D sfh' lkqgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appro Elate regional office of the Department. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts H : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'" 381 Ames Way, Centerville Property Address Arthur& Rosemary Ristino 14 Hardy Lane Owner Owner's Name information is Hampton Falls NH 03844 6/25/2018 required for every �_ __ page. Citylrown 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 l ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Lv1 Were any of the system components pumped out in the previous two weeks? L2" ❑ Has the system received normal flows in the previous two week period? ❑ 2 Have large volumes of water been introduced to the system recently or as part of this inspection? 2/ ❑ Were as built plans of the system obtained and examined? (If they were not —/ available note as N/A) Ll� ❑ Was the facility or dwelling inspected for signs of sewage back up? ®� ❑ Was the site inspected for signs of break out? —/ �juG C,rl�jn L�' El Were all system components,�ing the&S, located on site? K? ❑ 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): ---13 Number of bedrooms (actual): — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3_7 O 15ins.doc-rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 381 Ames Way, Centerville Property Address - - Arthur& Rosemary Ristino 14 Hardy Lane_ Owner Owner's Name --" — information is Hampton Falls __ required for every NH _ 03_844 6/25/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes I''J No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes P/-No Laundry system inspected? ❑ Yes 9/No Seasonal use? dyes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 17 Detail: Sump pump? -- ❑ Yes [v]�No Last date of occupancy: �s!t'�"''�" cv'��e ire�k�nG�S�>�U ,� 7 Q C ! Date Type oi=Estpblishment: ---- —..--- __ _- Design flow(based o O CMR 15.203): Gallons per day(gpd) — --- Basis of design flow (seats/persons/sq,;ft., etc.): - -_..__..... Grease trap present? ❑ Yes ❑ No Industrial waste ho lding tank present. � ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? `" ❑ Yes ❑ No Water meter readings, if available: --------------- -- t5ins.doc•rev,6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 381 Ames Way, Centerville Property Address Arthur& Rosemary Ristino 14 Hardy Lane Owner Owners Name information is Hampton Falls _ NH 03844 6/25/2018 required for every _ page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of �cyluse: Date Other(describe below): General Information Pumping Records: r� �- � � „ �! ��SIGG Source of information: Was system pumped as part of the inspection? 2/yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ��' Type of yytem: 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 381 Ames Way, Centerville Property Address — Arthur& Rosemary Ristino 14 Hardy Lane Owner Owner's Name — information is Falls ton required for every Hampton _ NH 03844 _ 6/25/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 2-/No Building Sewer(locate on site plan): 74' � Depth below grade: feet Material of of construction: ❑ cast iron C9 40 PVC ❑ other(explain): Distance from private water supply well or suction line: �—� - feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) years ge �irrt��dNby a-C�rtifiieate�Crorn�rVi�rtce=%-(�tt�t�-a`-eerpy"vfi-eertii�e�te}M._.,__®.,-�s-{�.,-i�o--� Dimensions: G�/�/ 8 � �� C..ev-eL Sludge depth: 15ins.doc•rev.6/16 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 381 Ames Way, Centerville Property Address Arthur& Rosemary Ristino_ 14 Hardy Lane Owner Owner's Name - — - - -- - -- information is Ham ton Falls NH 03844 6/25/2018 required for every _—A_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle ----- Scum thickness d Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? � � > Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): IF ^� _G✓ � f�'—� �'� u �l 2i��S .G�t�. �oo?rf ouPa� Depth be grade: feet —_._—.__---.—_.----,.------_-_-._ Material of construe ❑ concrete ❑ meta ❑ 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.doc•rev.6116 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Ames Way, Centerville _ Property Address _ ^� Arthur& Rosem r Ristino 14 HardyLane Owner Owner's Name - -_--"-- information is p Ham ton Falls NH 03844 _ 6/25/201_8 required for every _ _ page. it Town State Zip Code Date of Inspection D. Information (cont.) Comments (on pu recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to vert, evidence of leakage, etc.): irate Sf-itq�peetiorlte-ors-ref D th below grade: — Material construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: -- - Capacity: — ---- _ — --- - __..--- gallons Design Flow: — -- - gallons per day Alarm present: E-1 Yes ❑ No Alarm level: ------- ATE m in working order: El Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): 4 *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - - Title 5 Official Inspection Form _ Ell Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M , 381 Ames Way, Centerville Property Address Arthur& Rosemary_Ristino 14 Hardy Owner Owner's Name — information is p required for every Hampton Falls NH 03844 6/25/2018 page. Cityrrown 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 -- -- 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 r Pumps in ng order: ❑ Yes ❑ No* Alarms in working order---� ❑ Yes ❑ No* Comments (note condition of pump ch leer, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why; 9 7?10 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts - - : Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 381 Ames Way, Centerville Property Address Arthur& Rosemary Ristino 14 Hardy Lane Owner Owner's Name ^— information is Ham ton Falls NH_ 03844 6/25/2018 required for every .___._� .._ _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ❑ leaching chambers number: --- — ❑ 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.): 1 11 t -7 �.e-e's' 6 �'�`z vim.r� o - 5' 4e-196e)-- Number eta configuration Depth —top of liquid to i t invert --- Depth of solids layer Depth of scum layer --- Dimensions of cesspool -- Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 'rite 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts -- L Title 5 Official Inspection Form 16 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Ames Way, Centerville Property Address — Arthur& Rosemary Ristino 14 Harder Lane Owner Owner's Name information is Hampton Falls NH 03844 6/25/2018 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Goo ruts (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -�..,,� �., * Y� }-- Materia�ls of construction: -- ---- Dimensions*",- °. Depth of solids Comments (note condition of soil, signs of h &a jic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Ames Way, Centerville Property Address Arthur& Rosemary Ristino 14 Hardy Lane _ Owner Owner's Name information is Hampton Falls NH 03844 6/25/2018 required for every page. Cityfrown 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 whe e public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately W 381 Ames Way CentervlUe, MA 02632 3 Bedroom Rear of' House B Deck A 1 p A l-16.1' B 1-23,0' 1000 Gallon H-10 2-21.0' 2-27.6' 2 O Septic Tank 3-23,6' 3-31.0' 4-36.0' 4-30.4' 4 3 p D-Box 6' Radius Leachpit w/ 3' stone t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 381 Ames Way, Centerville _ Property Address Arthur& Rosemary Ristino 14 Hardy Lane Owner Owner's Name information is p required for every Hampton Falls NH 03844 6/25/2018 _page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: heck Slope Surface water 7["( heck cellar Shallow wells Estimated depth to high ground water: feet — Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ 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: o 7 9 / Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc.rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 381 Ames Way, Centerville Property Address — Arthur& Rosemary Ristino 14 Hardy Lane Owner Owner's Name information is Ham ton Falls NH 03844 6/25/2018 required for every —__�_—__ page. City/Town State Zip Code Date of Inspection r E. Report Completeness Checklist E�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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Table 3-2 Do's and Don'ts of Private Septic System Management DO... DON'T... Do have the on-site system inspected and pumped by Do not use the toilet or sink as a trash can by a licensed professional approximately every 3 to 5 dumping non-blodegiradable material (clgarette butts, years. Failure to pump out the septic tank w cause diapers, feminine products, etc,) or grease down the system failure. If the tank fills up with an excess of sink or toilet. Non-biodegradable material can clog solids, the wastewater will not have enough time to the pipes,while grease can thicken and clog the settle in the tank. These excess solids will then pass on pipes. Store cooking.Vls, fats, and grease in a can to the leach field, where they will clog the drain lines for disposal in the garbage. and soil. Do know the location of the on-site system and drain Do not put paint thinner, polyurethane, anti-freeze, field, and keep a record of all Inspections, pumping, pesticides, some dyes, disinfectants, water repairs, contract or engineering work for future softeners, and other strong chemicals into the references. Keep a sketch of It handy for service visits, system. These can cause major upsets in the septic tank by killing the biological part of the on-site system and pollut.Ing the groundwater, Small amounts of standard household cleaners, drain cleansers, detergents, etc. will be diluted in the tank and should cause no damage to the system. Do grow grass or small plants (not trees or shrubs) Do not use a garbage grinder or disposal, which above the on-site system to hold the drain field in feeds into the on-site tank. If there Is one, severely place.Water conservation through creative limit its use.Adding food wastes or other solids landscaping is a great way to control excess runoff, reduces the system's capacity and increases the need to pump the on-site tank. If a grinder is used, the system must be pumped more often. I Do install water-conserving devices in faucets, Do not plant trees within 30 feet of the system or showerheads and toilets to reduce the volume of water park/drive over any part of the system. Tree roots will running into the on-site system. Repair dripping faucets clog pipes, and heavy vehicles may cause the drain and leaking toilets, run washing machines and field to collapse. dishwashers only when full, and avoid long showers. Do divert roof drains and surface water from driveways Do not allow anyone to repair qr pump the system and hillsides away from the on-site system. Keep sump without first checking that they are licensed system pumps and house footing drains away from the on-site professionals. system as well. Do take leftover hazardous chemicals to an approved Do not perform excessive laundry loads with a hazardous waste collection center for disposal. Use washing machine. Doing load after load does not bleach, disinfectants, and drain and toilet bowl cleaners allow the on-site tank time to adequately treat wastes sparingly and in accordance with product labels. and overwhelms the entire on-site system with i excess wastewater. This could flood the drain field without allowing sufficient recovery time. Consult with an on-site tank professional to determine the gallon capacity and number of loads per day that can safely I go into the system, Do use only on-site system additives that have been Do not use chemical solvents to clean the plumbing allowed for usage In Massachusetts by MA DEP. or on-site system. "Miracle" chemicals will kill Additives that are allowed for use In Massachusetts microorganisms that consume harmful wastes. have been determined not to produce a harmful effect These products can also cause groundwater ' to the individual system or its components or to the contamination environment at large. mp:/Mx v.mau.pov/doywetar/raaoxceclvnpqulde.doc �-17 July.?00 Commonwealth of Massachusetts T Title 5 Official Inspection Form- kot for Voluntary Assessments Subsurface Sewage Disposal System Form M ya y Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6115/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms the computer, r,use 381 Ames Way, Centerville, MA 02632 only the tab key Property Address to move your Author& Rosemarie Ristino cursor-do not Owner's Name use the return key. 18 Hillside Way Owner's Address Wilmington MA 01887-3329 Cityrrown State Zip Code Date of Inspection: 09/05/06 Date 2. Inspector: Mike Hudson Name of Inspector Septic-wiz Environmental Services Company Name 31 Midway Drive s; r Company Address - Centerville MA 02632 Cityrrown State Zip Code,. 508-367-5669 Telephone Number r r 7 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Nees Further Evaluation by the Local Approving Authority 09/11/06 Ins ctors Sig tur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 381 Ames Way Property Address Centerville MA 02632 City/Town State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection 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: A B) System Conditionally Passes: �I ❑ 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 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: Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 r Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 381 Ames Way Property Address Centerville MA 02632 City/Town State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection a 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 ❑ 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: NIA 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 Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 381 Ames Way Property Address Centerville MA 02632 Cityrrown State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection t C) Further Evaluation is Required by the Board of Health (cont.): NI� 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 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: Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 381 Ames Way Property Address Centerville MA 02632 Cityrrown State ZipCode Ristino 09/05/06 Owner's Name Date of Inspection 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 %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] Yes No ❑ ® 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. Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 381 Ames Way Property Address Centerville MA 02632 City/Town State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection (I� E) Large Systems: To be considered a-large system the system must serve a facility with a i� 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. Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Checklist 381 Ames Way Property Address Centerville MA 02632 City/Town State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection 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(3)(b)] Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 381 Ames Way Property Address Centerville MA 02632 Cityrrown State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 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 years usage(gpd)): 2004-186 GPD 2005-145 GPD Sump pump? ❑ Yes ® No Last date of occupancy: occupied May- Commercial/Industrial Flow Conditions: Sep only k 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: Last date of occupancy/use: Date Other(describe): Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 381 Ames Way Property Address Centerville MA 02632 Cityrrown State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Water Pollution Control-No records found Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 27 years old, engineer plan dated 06/17/79 Thomas Monahan PE on record w/home owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM C. System Information (cunt.) 381 Ames Way Property Address Centerville MA 02632 Citylrown State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): inlet pipe in good condition, no signs of leakage Septic Tank(locate on site plan): 11" Depth below grade: feet Material of construction: ® concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ® No certificate) Dimensions: 4'10'Wx8'6"Lx5'8"H - 1000 gallon Sludge depth: 4'11" (1"thickness) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness .25"or less Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured probe w/rag, tape, spot light Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4�M C. System Information (cont.) 381 Ames Way Property Address Centerville MA 02632 City/Town State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping every 3 years, inlet and outlet baffles in good condition, tank structurally sound, all liquid levels in relation to outlet invert normal, no evidence of leakage but some root intrusion thru the covers which was fixed Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i� 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): Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 381 Ames Way Property Address Centerville MA 02632 Cityrrown State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection Tight or Holding Tank(cont.) 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.): Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert .10, even w/outlet 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 level, outlet level, no solids or leakage. Root intrusion thru the d-box cover. Roots removed and cut back from d-box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 381 Ames Way Property Address Centerville MA 02632 Cityrrown State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection 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: Type: ® leaching pits number: (1)6'R w/3'stone ❑ leaching chambers number: ❑ 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.): Soil conditions suitable for leaching, loamy sand, no signs of hydraulic failure, ponding, damp soil or lush vegetation. 6'deep 1000 gallon leach pit w/3'washed stone. Stain line up sidewall 8"from bottom approximately 5' under inlet pipe. Overall in excellent condition showing very low usage. Ristino-T54nspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form C. System Information (cont.) 381 Ames Way Property Address Centerville MA 02632 City/Town State Zip Code Ristino 09/05/06 Owners Name Date of Inspection !Y Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): I" Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .1 �( Privy(locate on site plan): 1" Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 381 Ames Way' Property Address Centerville MA 02632 City/Town State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection 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. W 381 Ames Way Centerville, MA 02632 3 Bedroom Rear of House B Deck A 1 O A l-16.1' B 1-23.0' 1000 Gallon H-10 2-21.0' 2-27.6' 2 Septic Tank 3-23.6' 3-31.0' 4-36.0' 4-30.4' 4 3 E 0 D-Box 6' Radius Leachpit w/ 3' stone - -_......._...... Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 L Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 381 Ames Way Property Address Centerville MA 02632 Cityrrown State Zip Code Ristino 09/05/06 Owner's Name Date of Inspection Site Exam: Slope 431. 1 Surface water 1-3 ( 4 Check cellar NA e-S Shallow wells t-3 1 n' Estimated depth to ground water: 1 0 t -}- 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: 09/05/06 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: Reviewed USGS topographic map and water resource maps You must describe how you established the high ground water elevation: Reviewed egineer design plan perc data dated 06/15/79 by Thomas Monahan PE, reviewed USGS topographic map and water resource map for subject property Ristino-T5-Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 No................ .J _ Fxs.............................. THT-_ COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town ... ...............OF......Barnstable ..... .....- -- --- -------------...................................-........... App iration for Uhipvii al Workfi (fnntitrnrtiun ramit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: Lot 1 Ames Way , Centervilles ................--................................................................................ -•.......--------•...•----•-••-•--------•---••.._....-•-•-----•-----------------•----------------- Loc tion-Address or Lot No. .............."1R-_ ..K ... 'RT.AQ-1--.-_ � T..I.f�� ._.fit?C� I.t� T� ._). - .t5S.............................. Owner Address Installer Address 16 $76 Type of Building Size .1.876 Size feet U Dwelling—No. of Bedrooms..............3...........................Expansion Attic ( ) Garbage Grinder (nq Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------------- - W Design Flow............... ---------i���_gallons per person Wj fluty. Total dlaFil . flow---_.-----------330-----•-----------.gallons. WSeptic Tank—Liquid capacity............gallons Length._............_.. Width................ Diameter_.-_.__..._..... Depth........._...... x Disposal Trench—No .................... Wid . _--------------- Total Length_.._____. __ Total leaching area--------- ._ sq. ft. Seepage Pit NO...... ............ Diameter....��t._..... Depth below inlet......_..t....... Total leaching area.....2b7_....sq. ft. Z Other Distribution box ( )0 Dosing tank ( ) Percolation Test Results Performed b0a-pQ---Cod--Survey---Consnitant-s Date.....6/11/79............... 1.4 Test Pit No. 1__2...........minutes per inch Depth of Test Pit.....12..1....... Depth to ground water.rl ne____---__._- Lz, Test Pit No. 2................minutes per inch Depth of Test Pit..............._---- Depth to ground water........................ a -••••---•--•-••-------------••-•-••---------•••-•-------•-•-••-.....-••-----•-•-•..................._..........---.........-•----•-----------.........---•-- 0 Description of Soil..Q.D_O.4... rood---loaz7---0,.5-1.->`---suhso l-,----1.-5--4,5...»eEl--- --s-e------------ --------------------------------sand,... ...8,0-i,2,0---med,...fine- W ---------------------------------------------------- .......... . U Nature of Repairs or Alterations—Answer when applicable- o� . ..... THOMAS =,� Agreement: MONAHAN C i The undersigned agrees to install the aforedescribed Individual Sewage Disposal st 41R'�(Cocorda c�i th 10 the provisions of iIlL 5 of the State Sanitary Code— The undersigned further agrees 9¢f_ �s�e� in operation until a Certificate of Compliance has been issued by the board of health. F S/0N4 in ? Si ed---. Date�y Application Approved By.......-- --• ... •----- ` _y ----�11. ... Date i Application Disapproved for the following reasons:.....................V--------••--•------------•----•-•-•---•--------•------•-----•-----•-•--•--•----•-------- ---------------- --•--•-•--•------------ -•--•----------------- ---•-------- •-•----•--••-•----------------- ------------------------------------ Date Permit No......................................................... Issued... l .. -------- .............. Date a .,.r M 1 { FE ...............'� . No. S TA COMMONWEALTH OF MASSACHUSETTS J , BOARD OF HEALTH y.... T-awTI.....................OF.....Barnstable AppUration for Uiipngal WorkiVi Tomtrurtbatt ramit Application is hereby made for a Permit to Construct' O or Repair ( ) an Individual Sewage Disposal System at: Lot Amea 'Way Centarvilles .........--•-•-.... •- -•--- ------------------- ------------•- -•-----••--------------•--- Location-Address or Lot No 2 ?"± _.AR:.'.1 .QR,.. . a-TwO ., &Ws.5............................... Owner Address \1E. ;:Q:�:l.?�o _... r_y.?�t�s............. ����.��� I��LE --•--•-••-•-•--- Installer Address Q Type of Building Size Lot. .64. 1 ..........Sq. feet aDwelling—No. of Bedrooms.............. ............................Expansion Attic ( ) Garbage Grinder (11M) p, Other—Type of Building ............................'�No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fix es ••-•••..............•---•-- W Design Flow............................. .gallons per person ere y. Total daily�flflow____._ 3 ._.gallons. WSeptic Tank—Liquid capacity!- -".gallons Length..... ......... Width__ -4....___. Diameter__.__ -_-_____- Depth 11. ?...... x Disposal Trench—No..................... Width.................... Total Length..... _�_._..._ Total leaching area..{.f...__.......sq. ft. Seepage Pit No..................... Diameter------ `.......... Depth below inlet...... Total leaching area..._? 7------sq. ft. Z 'Other Distribution box ( X) Dosing tank ( ) Percolation Test Results Performed ^ : _. i .n :} _ Date.... ' / --.. Test Pit No. 1.2............minutes per inch Depth of Test Pit----- R Depth to ground water Gx, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground,wa.-ter........................ O Description of Soil. , ,. V .�#dr __-f+,,,�,. ... _,_' s _ , P �'-d-�- � ��-... > y�c'�-ar€3-�.,��---- s-�-+�.. •-•;tli�� ---�fi3��` -•----•----- ---------------------------------Sand-,...4.->---_ -. r 8-wQ-1.2-w0..m &----tine---Sam- ----------------------- W -•--•---------------------------------•-••-•--•••••-----------•-----••--•--------...---•--•...-----------------------------------------------------------------------••-•-••-••--•................... UNature of Repairs or Alterations—Answer when applicable....................................................•.._................__._._...__........_.__. ----------------------------•---•----•- •-••----•-•----------•-•--••----•------------....---....--•--------------------------------------------------------------------•------------------..........•••• Agreement: The undersigned agrees-to install the aforedescribed Individual Sewage Disposal System in accordance with s the provisions of i I L is 5 of the State Sari.itary Code— The undersigned further agrees-not to place the system in operation until a Certificate of Compliance-has been issued by the board of health. Sied -•--- ---•---------------------•----.------ ,/� Dat Application Approved By.. .. ... -- ---- ... . ................. " Date Application Disapproved for the following reasons----------------•••-• ---------------------------------------------------- �r ----------- s Date PermitNo........................................................... Issued_....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ' ..... OF.... ............................ Trr#ifirttir of Mimpfittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (V<10/r Repaired ( ) by------V-F--. Z04CA---... ----------------------------------------------------------------------------------------------------------------- Installer has been installed in accordance with the provisions of LWAVYr of Th State Sanitary Cod as described in the application for Disposal Works Construction Permit N / .-_._..-. da.ted___._- '" r "t�'--7----•.---••--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F NCTION SATISFACTORY. DATE............... l.-..�'C.....-------•---...------• Inspector: ---•-- - ----------••-- . ..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O.V ............ No......... ............... FEE.. ................. �i��rr��t1 nrk� �a�n�firnrr�i�rn �ernti� Permission is hereby granted._...W�Jo j.1.3�t.�. _....::"bQo.A...��� --------------•---------------•---......._. to Construct ( or Repair ( ) an Individual Sewage Disposal System at No.._!:-==.....I...... E-;�L------t!�N . = Street as shown on the application for Disposal Works Construction Per . o.__--._ .. ated....�:7/P..'r?,�.......... n --- rd" 4 --------------------------•-- {j 7j Board of Health DATE.........------................ --• ..... .................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS l0 CAT 19� � SEWAGE PERMIT N0. 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