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Home My WebLink About0143 ANSEL HOWLAND ROAD - Health 143 Ansel Howland Road, Centerville MM Sllll_�_/1 J�vs�uca No.2 12534 3LOR NASTINGG*UN 11/1/2019 ShowAsbuilt(1653x2338) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd _ Property Address - H_ALEY,.JOHN R&EDNAP Owner Umer's Name - ...._ . information Is - required for'every Centerville .. .... MA ._. _02632..__ 6t24/2015, .page: City/TomState Zip code _ Date:of Inspection D. System Information (cont.) Sketch Of SeAa e$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 belowi ® hand.sketch in the area below ❑ drawing attached separately Back of house A B r 2' 3 A1)27 A2)37 A3)51 31)47 BZ)51 B3)46 'k9ni•1i3 TWO 5A@!isl IMeAai Form sibsurfigm Sagep9[1lSPo SYsteiri•k9a 15 d'17 https://itsgldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=171234&sq=2 1/1 1 f r .fi No. 1" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS appYitation for Disposal, pStem Construction 3pPrmit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System ndividual Components Loc7 7S dr ss or Lot o. Ownery Name,Address,and Tel.No. Assessor's Map cel f Z Installl/leuur's Name,Address,and ��T��1..N�No. D ner's Name,Address,a Tel.No. y Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 2� j Number of sheets Revision Date Title r C Size of Septic Tank Type of S.A.S. G �y C� Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 syste i operation until a Certificate of Compliance has been issued by this Board o ealth,_CL --I Si ed Date Application Approved by Date: g 15 Application Disapproved by Date for the following reasons Permit No. 1 Date Issued 15 -s • No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF-BARNSTABLE, MASSACHUSETTS Yes 01pplication for Vsposa�, .?pStem Construction Permit Application for a Permit to Construct(,.) ; Repair(grade( ) Abandon(` ) ❑Complete System ndividual Components Locati�o Address /or Lot No. / 44D Owner's Name,Address,and Tel.No. Ass�ssoMap/P ce / Zv� �� if Installer's Name,Address,and T 1.No. . Designer's Name,Address,aild Tel.No. Caw God -t Z s I Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) �n Other Fixtures Design Flow(min.required) � � gpd Design flow provided gpd Plan Date /Q _Number of sheets Revision Date Title rC Size of Septic Tank ' / � yp o S.A.S. � i f Description of Soil , 'C'" �i y�J, � x Nature of Repairs or Alterations(Answer4h6n applicable) L Date last inspected: ` Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sew4ge disposal system in 4 accordance with the provisions of Title 5 of the Environmental Code and not to place the syste i operation until a Certificate of Compliance has been issued by'this Board o ealth. Sig,ed 7 Date F;5)t7)71b)"� Application Approved by Date 5 F Application Disapproved by Date for the following reasons r Permit No. I5 Date Issued _ L4 t F F THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,,tthat ttthe On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandon d( )by �^t' , �iw+� ��^ at�� `ri- eA wL✓ � 11D has been constructed in accordance J with the provisions,o^f CAW) 5 'anal the for Disposal System Construction Permit No%/5"� dated Installer CAW) 3� nik-q Designer #bedrooms Approved design flow 4 god I The issuance of this permit shall not be construed as a guarantee that the system will \ncti� d'esignedd Date ! i S Inspector �'� No. ��l .5 �r} Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 3 Lj�/`, Pt XQL,1 --t� Q_D4Q and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed 11within three years of the date of this permit. Date � ) -� / l 5 Approved by \ Town of Barnstable �I"E'°'+ Regulatory Services Richard V. Seah,Interim Director a s + BARNSTABM MASS. Public Health Division �p i6gq. �0 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Vi'W10 Sewage Permit#ZU15=Z T? Assesssor''sMap\ParcelDesign6: A Installer: Address: CA�� Address: On Z.q �� `l h was issued a permit to install a (dat (installer) septic system at based on a design drawn by (address) dated v zo (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I ce .fy that the system referenced above was construc_;�- _.,;*�liance with the terms of t e IAA approval letters (if applicable) UAVIU .Y MASON i SON `MA tal ignature) No.loss Gam, GIs fe�l '10TAM 'it es1 r s gnature) (Affix Designers Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc TOWN OF BARNSTABLE LOCATION 15_4 Z / IL14,Q SEWAGE#ZO/'5% oZ F9 t� VILLAG Q,V i+C2 W/LPL ASSESSOR'S MAP&PARCEL / -a3 INSTALLER'S NAME&PHONE NO.I�/.J4QQM4 C 617s f /29S'� SEPTIC TANK CAPACITY lOGV LEACHING FACILITY: (type L-)t5Zy C'fVgM&XS (size) NO.OF BEDROOMS L OWNER��e(A �9G�GZ PERMIT DATE: COMPLIANCE DATE: /0 1 / 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 �� \ � �� e �` �3 �.�1 ® \ �� ( n O 3 �T�e� �.W IN� Town of Barnstable P# 7 7� Department of Regulatory Services aARNBGBLE. Public Health Division Date MA&4 200 Main Street,Hyannis MA 02601 •,ry Date Scheduled Time V✓T 11 Fee Pd. UU ! 7 lam'"l •.a Soil Suitability Assessment for Sew e A posal � my ,. Performed By: Witnessed By. ✓ i'1 LOCATION&GENERAL INFORMATLQN.+ Locat';n p�ess Owner's Name IrJLN I %/ i`J'll► i "�(d Address 1 Assessor's Map/Parcel: 113 y , Engineer's Name„ NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line It Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) �l Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation Hole# Time at 9" Depth of Pere Time at 6" 1 Start Pre-soak Time @ 2 Time(9"-6") End Pre-soak Rate MinAnch ` •v/• t Site Suitability Assessment: Site Passed—ilSite Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) �t Imo DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis[encv%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Graven Flood Insurance Rate Mao: Above 500 year flood boundary No /Yes Within 500 year boundary NoV7 Yes Within 100 year flood boundary No Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occturing pe io terial exist in all areas observed throughout the area proposed for the soil absorption system? w'^ If not,what is the depth o na Ily occurring pe ious material? r`t Certification (j I certify that on l ` (date)I have passed the sod evaluator examination approved by the Department of Enviro ental ProtpQon and that the above analysis was performed by me consistent with the re u' d training,expertise a d e pe c d ibe in 310 CMR 15.017. Signatur Date �0 U �� Q:\SEPTIC\PERCFORM.DOC V Town of Barnstable Barnstable .� Regulatory Services Department Alfteftj KA&% E I Im 619. Public Health Division 200 Main Street, Hyannis-MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 4930 July 20, 2015 John R. &Edna P. Haley 143 Ansel Howland Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 . The septic system located at 143 Ansel Howland Road, Centerville, MA was last inspected on 6/24/2015,by Trevor Kellett, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or-cesspool. You are ordered to repair or replace the septic system within one(1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Tho as McKean, R.S., CHO v— 9 Agent of the Board of Health N r s� Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\143 Ansel Howland Rd Cent Jul 20 2015.doc 7/17/2015 Parcel Detail :. T tip j`-�"-.v..,.�r'►".�,"."`_ , 1 iJ '°� 4'..„ 1 , 1 � r' rc :7 NAA S / .. I * �' •f�, _ - ~ - Logged In As: — Parcel Detail _ I ridgy, July 17 2015 Parcel Lcokuro Parcel Info Parcel ID 171-234 Developer Lot LOT 9 Location 143 ANSEL HOWLAND Pri Frontage 100 Sec Road Sec Frontage village CENTERVILLE Fire District C-O-MM Town sewer exists at this address No Road Index 0059 �. Interactive Map Owner Info owner'HALEY, JOHN R& EDNA Co - ownerOwnee r streets 143 ANSEL HOWLAND Streetz O city CENTERVILLE ` state MA zip 02632 Country Land Info Acres 0.35 (use Single Fam MDL-01 zoning RC I Nghbd 0105 Topography . Road i Utilities Location Construction Info Building 1 of 1 Year 1983 Roof Gable/Hip Et Wood Shingle T Built Struct Wall g Living 1432 Roof Asp p h/F GIs/Cmp Ac Central 1 Area Cover Type' style Ranch wall nt Drywall Rooms 2 Bedrooms Model Residential Floor Hardwood R ours 2 Fullin Bath -0 Half, I Grade Average Plus Type Hot Water Rooms 6 Rooms Heat Found- stories 1 Story ._� Fuel GaS ation Poured Conc. Gross 3406 .. _ A rea Permit History Issue Date Purpose Permit# Amount Insp Date Comments Visit History Date Who Purpose http:/fiissq l2/intranet/propdata/Parcel Detai l.aspPID=11688 1/3 �tME tqy, Town of Barnstable • r + BARNBCABLE, p "�: ,�� Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE 1 YEAR DEADLINE CRITERIA Static liquid level in the distribution box above outlet-invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis.,(This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER ❑ Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 I.» 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name ` information is r° required for every Centerville MA 02632 6/24/2015 I'y 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 A. General Information filling out forms ®g �f on the computer, C J ! I use only the tab 1. Inspector: key to move your cursor-do not Trevor Kellett use the return Name of Inspector trey. TK Septic Inspections �y Company flame , 38 Vacation Lane Company Address West Yarmouth MA 02673 City/Town State Zip Code 508-579-5502 S113744 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported-below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/26/15 Inspector's Signature Date The system inspector shall submit'a copy of this inspection report to the Approving Authority(Board . of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 V Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R &EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 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•3/13 Title 5 Official Inspection Form:Sub.surface.Sewage.Disposal system•Page 2,017 Commonwealth of Massachusetts l- Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �. 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is Centerville MA 02632 6/24/2015 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health). ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment; ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 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 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is Centerville MA 02632 6/24/2015 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection El 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•W13 Me 5 Otfidal Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? . ® ❑ Were as built plans of the system obtained and examined?(If they were not . available note as N/A), ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on.- Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15,302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Title 5 Offidal inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form pSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: This is a standard title v with a tank d box and leach pit 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R &EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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): Mrs-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. Gity/To` n State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 10-2M3 per boh Were sewage odors detected when arriving at the site? ❑ Yes M No Building Sewer(locate on site plan): 1.9 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1.4 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: 100og 4" Sludge depth: t!Jms•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN'R&EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 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 29 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank is structurally sound and water tight with liquid at the outlet invert, both tees are fine,tank does not need to be pumped, however due to back up there is a lot of scum all over the tank 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•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w. 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 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 worldng order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection form Ins p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert outlet submerged Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): d box is level and water tight with no carryover, 1 inlet and one outlet, d box is down 21", the d box is completely submerged two patio block are being used for a cover and the the soil above is stained 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.): *If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 I i Commonwealth of Massachusetts . Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd. Property Address HALEY, JOHN R &EDNA P Omer Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): This leaching is a single leach pit that is filled to the top with liquid ans the soil above is wet and stained 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 I Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5'Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R &EDNA P Owner owner's Name information is required for every Centerville MA 02632' 6/24/2015 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 o1 17 t Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w. . 143 Ansel Howland Rd Property Address HALEY, JOHN R&EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. City/Town 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 Back of house A B 1 2 3 A1)27 A2)37 A3)51 B1)47 B2)51 B3)46 t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official, InspectionForm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Ansel Howland Rd Property Address HALEY, JOHN R &EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 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. 50 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: 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: USGS Maps show GW at 51 feet Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 (� 143 Ansel Howland Rd Property Address HALEY, JOHN R &EDNA P Owner Owner's Name information is required for every Centerville MA 02632 6/24/2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked M Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Z System information—Estimated depth to high groundwater 0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins 3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF M.ASSAC14VSETTS ,_ EXECUTIVE OFFICE OF ENNIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONNIE\TAL PROT nn ®�*' ONE WINTER STREET. BOSTON. SIA 0=106 UILLIAN'F WELD P" T L'DN'C0\E Govemc• . 0 C r 2 4 1997 __ se:tetw% ARGEO PALL CELLUCCI Tp WN D.—1 B STRLMS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI RM HEAU HDEPr.. Commissioner PART A CERTIFICATION Property Address: �� t� ti� �W\0-*3A W i�T_fy-b1rSAddress of Owner: Date of Inspection: D` pf different) S Name of Inspector: ��elco 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 13.000) Company Name:A}/(_g"4-,-.r En rr-/',.g '"P ",�-e�� Mailing Address: R e3 /Io,c e 3�0!�j H,#!9a4ee_CL H i9- p a-ce ' Telephone Number: rS'ai4Z ��— /Lrc Zev CERTIFICATION STATEME\T I certii that I have personall% inspected the sewage disposal system at this address and tha: the rniormation reported below is true, accurate and comolete as of the time of mspee o-. The inspection was performed based on my training and experjence in the proper function and maintenance of on-site sewage disposa systems. The system: Passes _ Conc t o^aii, Passes %eecs Furtne• E%a!uat:on B� the Local Approving Authorm F `� Q Inspector's Signatur; W Date: \ 1 The Svs:eT Inspec0' sha" submit a cop of this inspecion report to the Approving Authority within thirty (30! days of completing this inspector.. It the sNsterr is a shared system or ha; a design flow of 10,000 god or greater, the inspector and the system owner shall submit the repo^ to the aaprooriate reeior.al ofiice of the Department of Environmenta! Protector The orig!na! should be sent to the system owner and copes sent to the buver, if applicable, and the approving authority INSPECTIO% SUMMARY: Check A, B, C, or D! A) SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. -` COMMENTS. 4rt Qwss�+t vn G CA wA Wxk kv,►Ua&%vu ;, -� S 45- VV,.L vrA o �t.T s�6T1'�c�RTvV�1� `�•t. BJ SYSTEM CONDITIONALLY PASSES: gl.C).vf 64L P�bk�S t ObThlf KC �tywYwt�, 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. Indicate 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 tattached) 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, (rev;.sed a/25/11) sage i of io DEo or,trio winnm vAm-wo- him IAww meamet state iris wwoer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10% FORM PART A CERTIFICATION (continued) Property Address: Owner: �. Date of Inspection: Bj SYSTEM CONDITIONALLY PASSES tcontini-d .0 g Sewa a backup,or breakout or high static water level observed in t distribution box is due to broken or obstructed prpe:s).or due to aibroken, settled or uneven distribution box. The system will pass inspection if(with approval of-theBoard of Healthi` 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 du to broken or obstructed pipe(s). The system will pass rnsoection if(with approval of the Board of Health): broken prpew are replaced obstruction is removed C) FURTHER EVALUATIO% IS REQUIRED BY THE BOARD OF HEALT Conditions exist which reouire further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, saiery and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMIENT: Cesspool or prn� ,s within 50 fee; of a surface ater Cesspool or pri%) r5 N ithrn 50 feet of a border g vegetated wetland or a salt ewsh. 2) SYSTEM MILL FAIL UNLESS THE BOARD OF HEALT (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER TH PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONME%T: The system has a septic tank and soil abso tron system (SKIS)and the SAS is within 100 feet to a surface water supply or t►ibutan• to a surface water supply. The system has a septic tank and soil ab rptron system and the SAS is within a Zone I of a public water sup-)Iv well. The system has a septic tank and soil a orption system and the SAS is within 50 feet of a private water supply I •well. The system has a septic tank and soil a sorption system and the SAS is less than. 100 feet but 50 feet or more from a private water supply well, uniess a we I water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from t t facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to d ermine distance (app►oxitaation not valid). 3) OTHER (revised 04,25/9') say. 2 of 10 r T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO'% FORA PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes' or 'No* as to each of the follmoing I have determined that the system violates one or more of the following failure c terra as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be cont ed to determine what will be necessary to correct the failure. Yes No _ Backvp of sewage into facility or system component due to an erloaded or clogged SAS or cesspool. Discharge or pon•drng of effluent to:the.surface-of the ground r surface waters due to an overloaded or clogged SAS or cesspool Static houid level in the distribution bo), above outlet rnv rt due to an overloaded or clogged SkS or cesspool. Liquid depth it,. cesspool is less than 6" below invert or available volume is iess than 112 day floe. Reou-red pumping more than 4 times in the last year OT due to clogged or obstructeo pipes . Number o;times pumped_. Any portion o'the Soil Absorption System, cessp I or privy is below the high groundwater elevation, Am por;;on of a cesspool or privy is within 10 feet of a surface water supph• or tributan to a suriace water supple. And poi-ion of a cesspoo' or prn- is within Zone I of a public well. Any ponlo- e-'a cesspool or privy is w•rthi 50 feet of a private water supph well Any por;.or. o;a cesspool or privy, rs lee than 100 feet but greater than 50 feet from a private water supply well with no acceo;abie water qualm analysis. If th well has been analyzed to be acceptable. attach cope of well water analysis for coliforrr• bacteria .olat le organic co, ounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate ether "Yes' o• "%o•' as to each of he following: The ioliow,ng criter,z app;% to large syste sin addition to the criteria above: The system serves a facilm with a deli flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safes and the envrr ment because one or more of the following conditions exist: Yes No the system is within 400 eet of a surface drinking water supply the system is within 2 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 ell) The owner or operator of any such s tem shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and .00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propert%Address: `A3 PN';k1 VpjJµ� do d Owner: S Date of Inspection: *o\qn Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ygs 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 bu,l: plans have been oo:a:ned and examined. Note if they are not available with N/A. _ The fac,l,;x or d%.ellmg %%as inspected for signs o!'sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site vas inspected for signs of breakout. All sv steT. components. excluding the So+' Absorption System, have been located on the site. n•, _ The septic tank manhoies mere uncovered, opened. and the interior of the septic tank was inspected for condition of —1 banies or tees. materia; o' construction, dimensions, depth of liquid, depth of sludge,depth of scum. —The size and location of the Soi' .Absorption Svsiern on the site has been determined based on: The iacdti\ o%sne• ;ano occupants. if d,fteren: from oo•nen were provided with information on the proper maintenance of Sub-Suriace Disposal Svsierr. WI� Existing information. Ex. Plan at B.O.H. Determined in the field of an% of the failure criteria related to Part C is at issue, approximation of distance is unacceptable 115.302.31 b`! (sevaead 0�/2S/57, Page 4 of 10 I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propert% Address: N'vW Owner: (AV to Date of Inspection: RESIDENTIAL: FLOW CONDITIONS Design floe. ;Q0 ¢o.d.lbedroorr. for S.q S Number of becrooms-0—z— Number o-current residents L Garbage 91, der (yes or no, Laundry co-•^ected to system (,yes or no` Seasonal use (yes or no�.—UD Water meter readings, if available (last two i2 vear usage tgpd): Sump Pump Ives or not Las-, date o-*occupancy COMMERCIAUMDUSTRIAL• Type of establishmen: Design fio%% ¢alions•da\ Grease trap present wes or no_ Industna! 1%aste Holding Tani; Present ves or no 'ion-sanitan. Haste discnargec to the T!t,e 5 sysem ives or no_ \later meter readings. if availabie Las:pa:e o: o c,;p2-.c\ OTHER: .De:cribe Last care of occ,cane, GENERAL INFORMATION PUMPING NRDS nd so rce of infcmano 1 . 1D Syst pumpe as par, of mspecion: Ives or n If yes, volume pumped ¢allons Reason for pumping TYPE OF SYSTEM Septic tanVdistnbution bozrsoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: 11JS.%Ay Sewage odors detected when arriving at the site. (yes or no)�v (revlaed 04/25/97) page 5 of 20 SUBSURFACE SEA%AGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) Properh Address: V3j, Owner-. Date of Inspection: BUILDING SEWER: (Locate on site plan) Q" Depth below grade. Material of construction. _cast iron _40 P`,C _other texplaW Distance from private water supply well or suction I1-e Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site pl n Depth below grade tf Material of constructio^. _concrete _me;z _F oe g a_.s5 _Polyethylene _othenex Plain' If tank is meta". Iis; age _ Is age confirmec b\ Ce^itica.e of Compliance _(hes.!No Dimensions 1000 q w Sludge depth —0 D'siance from top of sludee to bonorn of outie: tee o• b2'�e Scum thickness Distance from top o;scum to top o; outlet tee or ba-* Distance from bonorn o scurn to bo"o n o�t e o• ba*,e How dimensions v.ere determ,ned Comments trecommendation for pumping condition w inlet and outlet tees or baffles, de th of liquid level in relation to outlet invert, tructurDUVAias I i egrity, evidence of leakage. etc. w � � v o GREASE TRAP: (locate on site plan: Depth below grade. 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 Comments: (recommendation for pumping, condition of i,ilet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.; ilrevisad 04i25.17) P&9* 6 of 10 I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR%i PART C SYSTEM INFORMATION (continued) Propert% Address: O%ner: kqii,%j6.jjLS Date of Inspection: TIGHT OR HOLDING TANK: 00'Tank must be pumped prior to, or at time, of inspection! (locate on site plan: Depth below grade Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity. gallons Desir flov, galions-da, Alarm ]eve! A:arm in „or icing order _ Yes: _ No Date of previous pumping Comments (condition of inlet tee condauor,. o* a!a,m and float switches. etc.) DISTRIBUTION BOX: docate on site p:a-: Dept^ o' houid le%e' aoove ouue: ime^ Comments ote eve' an dar L eaua evid.en of solids carryover, vidence of I a e to out of box, etc.) PUMP CHAMBER: NV (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.) (revamed 04/25/9") Page I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION (continued) Proper Address: y?j pf pCQ\ \Ap Aj`6, `A Ej Owner:"I�?N,.V&4�Z Date of Inspection: CA SOIL ABSORPTION SYSTEM1(SAS):AQCC (locate on srte.plan, n possible, exca%atio not required, but may be approximated by non-intrusive methods, If not determined to be present, explain Type: leaching pits, number t�(oxfo leaching chambers, number._ leaching galleries, number. leaching trenches. number,iength: leaching fields, number, di-nens+o.n.i ovei=!ow cesspool, number Alternative s%,stem Name of Techno)og\ Comments. to re condition of soli, s!grs of h,draulic failure, levei of ponding, condition of vegetation, etc.( otr� 11X S�PrI;T� S of t N V( U✓ 'N S' CESSPOOLS: N V (locate on site plan. Number and configura:,on Depth-top of liquid to inlet Inver, Depth of solids layer Depth of scum layer. Dimensions of cesspoo;. Materials of construction Indication of groundwate- inflow tcesspool must oe pumpec; as par, of inspection:, Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plant Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) sap• I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO-N, FORM PART C SYSTEM INFORMATION (continued) Property Address: J tire\ wow\0.. Owner: 'V-t V(2k& Date of Inspection: 1 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) 3 a - �Z 3� Viz-Kg (revised 04125/4') rage 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: P41-3 Owner:—TPt\/("n-f'S Date of Inspection:Ilzo i Depth to Groundwatert-1 Fee; Please indicate all the methods used to determine High Groundwater Elevation: Obtained iron Design Plans on record Observation of Site (Abutting property, obsenation hole, basement sump etc:) Determine it from local conditions Cnec'K %%ah local Board o• neaar Checs. FEntA naps Check pumping records Check loca' e).ca�ato,s installers l se :SCS Da-a r• Describe in %ox ors %%o,oz ro••, %o: es:abh hec the yigh Groundwater Elevation. (Must be completed• I N0 t:ev;.sed 24:2519-. Page 10 of 20 No.. ��- ....1. Fxs.. ................. /43 THE COMMONWEALTH OF MASSACHUSETTS ( , 3 BOARD .O-F-HEALTH .../ .ci' t..............0 F........... .......... Applirattun for Ui4puml Work.5 Tomitrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....... .. ................................ .............. .�...........-•---...... •--•••--••••......•--•---••-............. ... .... Location.Address o t No. ..... ... ......... ............................... Owner Address W ------------------ ......._..cam ......... ................ ........................................... Installer Address dType of Building Size Lot.__. 5. �_..Sq. feet U Dwelling—No. of Bedrooms... .....................Expansion Attic ( C. j Garbage Grinder (Aj., J Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria.( ) a Other fixtures -•-•----------- --------------- W Design Flow..... Z .............. .......gallons per person per day. Total daily flow......,,t5'..3 5....................gallons. WSeptic Tank—Liquid capacity.-Zallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—1 o. .... .............. W•dth_.._................ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------ p� Diamet - !"�Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-, Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W . ODescription of Soil.......57-------------------------------------------------------------------------------------------- ----------•---•-----------.........----•----_.. x 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 p isions of iITL L 5 of the State Sanitary Code— The undersigned.further agrees not to place the system in op a ' u it a er, •fi to Compliance has been issued by t e b rd of ealth. Signed----- 4..-•-- ' Date PPl• a o proved y-------- r...s/!.. ................................. ........................................ Date Ap l• tion Disapproved for the following reasons----------------------------•-•-•-------•----------------------•----•--------•--•----------...................... -•------•-•........................•-----•------•--•-----................-•---------------........_....•. Date PermitNo..................................................... Issued........................................................ Date l_ No.._9 3-i 0" FEs............._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD �OF`.HEALTH ............... :... �o.:. Appliratiun for Bi,ipuuttl Works Tomitrurtion itamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Y f Location-Address - . or Lot No. f = ......... ••...........:..•-•-----...........................••.. Owner Address a Jet*->°} •c,_.itL` tt r Installer Address d Type of Building Size Lot.....`.......-a.?.f:0...Sq. feet U Dwelling—No. of Bedrooms___________�'' ;_....................Expansion Attic ( Y , . Garbage Grinder ( �} G) ____« aOther —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------•----------••••-•---•-----.................. ........................................................ W Design Flow...... .. ......................gallons per person per day. Total daily flow........t_.,�____..__....................gallons. WSeptic Tank—Liquid capacity_,& allons Length................ Width................ Diameter................ Depth................ Disposal Trench—:'To.____------•----._..- Width.................... Total Length.................... Total leaching area....................sq. ft. xSeepage Pit No.___._ ''..`..__ - Diametelfh�."'_x `.. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank 04 Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..................... GX, Test Pit No. 2................minutes.per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------•------•----•------------------•---..............-•-••-•-•--•............................................................ ODescription of Soil-------!-...............................................•-._......---•--•-•-•••••••-••••-••••-----••-••--••••••-••--••---•.....------•••-••......••••............-•-•- x U ---••--•-•-•---•--••-•••••-•••••••••-••--••••••••••-••••-------•---••-•-••--•••••••-----•---•-•••••••.......-••••••••-•----•••••••••••••-••-••-•--....•••••-•••-••-••••••...............•--•-•--........ 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 TITL- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in op at' rk"u til a ertificate Compliance has been issued by the board of health. ' Signed % ' = - (-•----••••---•-•................ ................................Date at o proved Y--------- .-�--•�--•/% ..jrf .=-•---•..........................•-- Date Ap li tion Disapproved for the following reasons:............................................................................................................... -----------------•------•--•-----•--------------•---•---------------•--•---------.....----....-•------.....----•--------------------------------•-------------------------•-----...--•-••••••••••-------- Date PermitNo..........................................----•........_. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... h Tnrtif iratr of Tontplittnrr THIS IS T CE�jjTIFY, at the Individual ewage Disposal System con�truc ( ) or Repaired ( ) by.. 1-- --•--... �-�'s� �Q......./. .- C `� ............................................ K--��--. Installer ------------- has been installed in accordance with the provisions of TITLB 5 o e State Sanitary Code as described in the application for Disposal Works Construction Permit No------- .3.'. � .......... dated................................................ THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONST U AS A GUARANTEE THAT THE SYSTEM WIL� CTION SATISFACTORY. DATE...ll.. Inspector .... ...---•....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ALTH ...............�d."x h ......OF.........................._..... '''' ..................... �Q No..... FEE........................ Dispouttl urku Tonitrttrtion unfit Permission is reby granted••••• - 1•'..••• QL,u.�,-.--.--••---------••-•------------------------------------------•-------......................_. to Construct6L) Repair ) an Individu Sewage Disposal System atNo......-•----.............. ............ -•----.. .-• -.....---....-' ----..-..------•-----------•-------•----------.-.---.-------.----------------.-------.---.-- Street as shown on the application for Disposal Works Construction rmit No....•__________ Dated.......................................... ...•...... . • ... . .................................................... _ Board of Health DATE............. ._.....----0---............----•-..................•-•....... FORM 1255 A. M. SULKIN, INC., BOSTON _` � L[�,Aj t:L-:13) . LOCATION �'� SEWAGE PERMIT NO. Lot 9 Ansel Howland Rd. 83-96LL VILLAGE Centerville INSTA LLER'S NAME i ADDRESS Robert B. Our Co. Inc. 1 Great Western Rd. N}rth Harwich, Klass. 02645 S U I L D E R OR OWNER Alan Small DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��/ 31� �fy `,I►.JGIL- .FAMt�`( - :6 BCD2001A 11 I ,I �o GARBAGE (�WtJDE2. , Ito x 5 = z3o"G.Pp II SEPTIG TA►JK = 33o><150% = g9iG.P. o y5E- 100o GAS.. IoL5Po5�L PtT v5>G � 5\DGWAt.� ARGa ►>o S.� � I ' BOTTOM AREA; 5.1~ x 1. 0 5 o G•P o. 'Y II -ToTA 1-. t7E51GN . ,425 G.P. D. �-z. 7 II 741TAL.. 1�.�( F�- 330 y ��oy PE2COLATION RATE - I"IN 2MIN oR LC-&55' _'F A e y31 L rAGN�~ ( U Q IIfm;HARD i :4 BAXTER H b J I, {'3 No.21048 �} ' ;iu 11. /`3lX. If,GI fan SUR*4 1 Q .T 6'�T loot/ lNv. i ,S�c3soic_ D 1 ST. INS/. C,P.r L S/• 8 .�vE�• Io0o rkr-A S�t.v,c7 Gat_. •S/. o �I /�ts�• PIT INV. INV. ,Sv4ND �' W 17 N .S/.z .S/• � G-P4✓ram � ,. I !� B , I �3/�•1 /L ii vJA�,,uGD 6TONG C� RTIFICD PL_oT PI-AW Ho, I p E KE GE it GE,RT1�'� THAT THE: ExL5TI►aG Fes- SNowN �{EREUIJ GoMP�-`(5 rIITN"tHE S 1 o6�1t�1 c:_2.__. � ET e*,:G o "(c> N O F aAQ TABLi--- A N U 051 II LOC-p.T ' D WITNI L 0 0 0 PL.b.IN A7gAXTEcZt IJ`(E INC. K.E6 I SZ 62EzD'LAW a "TIa15 PLQ►.1 16 NOrT anSFp o►d AN osTEczv,Ll � - MASS• it Iu5TR.uM6NT 5uevey( -THE 0t=F5E75 6WOULD H07 DE u5EDTa DETERI^IhI� �.or �_ INE`> AFF�! :o.t-tT f� ;'. :',� :��Lc�/�✓G. O _ AssEssoRs MAP : =� 1 ! TEST HOLE LOGS K�U PARCEL : � ;-)d ------------- 1) 'Idle installation Shall com,Ay +vith Title V ni-I Town of (11:1 1, ,�llu�u� of FLOOD ZONE: 09� SOIL EVALUATOR : I I UL� �� I Iealth Regulations. REFERENCE: 1 ��2 �} �LI -� WITNESS : 101 _ 5 2) 'I Ile installer shall verily (lie location of utilities, sewer inverts and septic _ � ppy'u __ DATE : Vt✓ 2` OI 1 , 1 components prior to installation and setting base elevalious. C 0L PERCOLAT ION RATE: G 1Ml t�.l 3) All gravity septic piping to be 4 inch Sch ,Ill PVC at 1/8" Im- lOot. 'I he first - ---- --- -- _ r two feet out of(he d-box to the icaching shall be level. 6JEC_ff. q 1903 �• '"`� y.�� f. � 4) "fliis plan is not to be utilized for property line determination nor any other TH- I TN-2 purpose other than the proposed system installation. 5) All septic components must nneet 'fitle V specifications. 6) Parking shall not be constructed over 1110 septic components. �wp � 6v�jJ 7) "l'he property is bounded by property corners and property lines. 8) 'Hie property owner shall review design considerations to approve or total LOCATION MAP 3\ ---- �� 3\ design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deenned approval of the design flow by the owner. �I�� C SI°r�,tl� �'A• ,� 9) "1 lie existing leaching or cesspools shall be pumped and filled with material per'fitle V abandonment procedures. "Those within the proposed SAS shall 1 09 ,��J I lb��.�I �ul Ll be removed along with contaminated soil and replaced with clean sand per l rile V specs. Ito la� !t I 10)System coruponents to be t0 feel from waterline. Sewer lines crossing the �0 *1 l'12' � water line shalt be sleeved with 4 inch SC11 10 PVC with ends grouted if /47769 applicable. 1 lie proposed SAS is being installed below the water service `�1►�� O line. The line is to be sleeved as aforementioned and maintained in place. rinder exists it is to be removed and is the responsibility of the SEPTIC SYSTEM DESIGN I l) If a garbage g Ga Rl o owner to ensure such. h O 12)1 he installer is to take caution in excavation around the gas line il`such FLOW ESTIMATE exists. U, 13)"I iie installer shall verify the location, quantity and elevation of the sewer Z� 1 _ I � BEDROOMS AT 1IO GAL/DAY/BEDROOM GAL/DAY Y 1 ' Y \ - N lines exitinn the dwelling brior to the installation. 14)'Ihis plan is representative only that a system can lit on a property meeting SEPTIC TANK 'i itie V requirements. GAL/DAY x 2 DAYS - UOD GAL USE ICON GALLON SEPTIC TANK �� q� t�OF T 2y�w DAV1p �9� ��N OF�q SOIL ABORPTI ON SYSTEM--- - _ _ - /a S. ��P ssy MASON � OAVlD S7 G '1 MASON 7xL v N 0. ° 66 '• I I `'� �I � y.�)11--� "1�� t7t..�^�.b1:.-� '�'�� ys4P,��tti(1r,19,�ss�,, __ �� , ,t 1 I - I SIDE AREA: Z yC ZS -l- tz,a� x E2, j7 -:7 BOTTOM AREA: Zw ?C �Z ?�� . X `� No. 1066 -a'� 3 L C > OFl4j'�S F��sr � . DAVIb B.-P T I C SYSTEM S E C T I O N MASON m DAM No.j0668. \ . fsz +A�Ast �"`"�. toy ��'" r' II - ( _..� 2.1r0G 3 ' r uz G1. tL �RY. 51� d 1D► �', a O �. o GAL mP !I krzl kzt I u + qt � SEPT I C TALK /�OIbVN C/f ICE✓I ..Roq1 I C) I SITE AND SEWAGE PLAN LOCAT I ON : I ��I� i✓ E'�D � �� 6L0< � l/t' 2U PREPARED FOR : l�`� � ►�L �,D�-(`jj12�( a C � l V SCALE : � = ----� �°R - D AV I D B . MA S O N R5 DATE : I Z DBC ENVIRONMENtfAL DESIGNS EAST SANDWICH . MA Z DATE HEALTH AGENT ( 508 ) 833- 2 177