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HomeMy WebLinkAbout0049 BACON LANE - Health 49 Bacon Lane Centerville P A = 207 019 ------. i a I Via/ J�aEI.YCLtpCo fay z 2F - UPC 12534 0 �� No. 2�153LOR HASTINGS. UN I o�9 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments elz �j 49 Bacon Lane Nj Property Address Michele Hardeman Owner Owner's Name - , information is Centerville Ma. 02632 07/19/2017 ' required for every page. City/Town State Zip Code Date of Inspection NrA�j Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information �"/� /RWO on the computer, V 1 use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections � Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 Si3938 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 ��77ZI2017 I spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc-rev.6/16 Title 5 Official Irispection Form:Subsurface Sewage Disposal System•Page 1 of 17 l°grd V5 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 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: ® 1 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: This 3 bedroom home has a main cesspool feeding an overflow cesspool and a pre cast leaching pit. At the time of the inspection both of the leaching conponetes were dry. 13) 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 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): I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the-system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I� Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form: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 wM 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 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): N/A Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): < 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (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: In 2016 75,000 gallons were used and in 2015 84,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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.doc•rev.6/16 Title 5 Official Inspection Form: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 wM 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is Centerville Ma. 02632 07/19/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Mike Bisienere Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: APPX. 500 gallonsgallons How was quantity pumped determined? Drivers est. Reason for pumping: cesspool 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): Main cesspool with an overflow cesspool and a leaching pit t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30",feet Material of construction: ❑ cast iron ®40 PVC clay ® 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: 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: Sludge depth: t5ins.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 M 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 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 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.): 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.doc-rev.6/16 Title 5 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 �M 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 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 N/A 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.): 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: one ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: one ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):. At the time of the inspection both were dry. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration One round Depth—top of liquid to inlet invert app. 3 feet Depth of solids layer 1 Depth of scum layer 1" Dimensions of cesspool appx. 6 x 6 Materials of construction block and brick Indication of groundwater inflow ❑ Yes ® No t5ins.doc-rev.6/16 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 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form !J9 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman mer Owners Name Ma 02g_ 32 07/19/2017 :)rmation is Centerville State Zip Code Date of Inspection auired for every Cityrrown ge. D. System Information (cont.) Sketch Of Sewage Disposal System: Pmarks or benchmarks. Lo ate ale a view of the sewage pwells within 100 feet includingosal system, olcates e at least two permanent reference land where public water supply enters the building. Check one of the boxes below: hand-ske c irl tth arreg lnw4hand-sn Me a e Ow 0 drawing attached sep?iacately ; LA z n P. r I . TWe 5 OWd top"-Foy.Sub � ��OSa1�°^•P�15 W.77 ins•341 Commonwealth of Massachusetts M v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville Ma. 02632 07/19/2017 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: 20 plus feet 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: I augered a hole at a lower elevation and shot it with a transit to show 5 plus feet of seperation. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is Centerville Ma. 02632 07/19/2017 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file o 4�' 02 0 5 PI J5 10, t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ug 04 1510:29p p.1 Commonwealth of Massachusetts �P aPI -on - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bacon Lane r, Property Address Michele Hardeman - Owner Owner's Name information a Centerville ✓ MA 02632 8-3-15 - required for every page. -Cityrrown 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 and of the form. Important:When A. General Information filling out forms ���oulluU�p on the computer, S/ `\\``�p �N OF Mgs�4ii,� kuse only to move t ob r 1. Inspector: !! ��U�! =S'�` .. �9L keyy a p . cursor-do not z • JAMES :m James D.Sears m= use the return Name of Inspector r key. sA v: :co CapewideEnterprises,LLC ,• o . Company Name � � Or 153 Commercial Street_— -- /���� 5,1INS��G��Op Company Address ------ Mashpee MA _ 02649 CityfTown State Zip Code 508-477-8877 S1623 TeleAhone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the informatiorr 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 8`3-15 2pe=dor'sgnature 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 wiff perform in the future under the same or different conditions of use. t5ins.3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Aug 04 15 10:30p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments rt 49 Bacon Lane Property Address Michele Hardeman Owner owners Name information is required for every Centerville MA 02632 8-3-15 page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E J always complete all of Section D A) System Passes: 1 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: The system is two block c pools and a pit 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, N D) 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 ❑ NO(Explain below): t5ins•3113 Title 5 Official Insaaction Form:Subsurreoe Sswae Oispawl System page 2 of 17 Aug 04 1510:30p p.3 Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information required for every Centerville MA 02632 8-3-15 page. City/Town Stale Zip Code Date of Inspection S. Certification (cont.) Q Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cant.): ❑ 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N [] NO (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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (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 wetfand or a salt marsh t5ir.s•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r -- Aug 04 15 10:30p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is CGnteryifle MA 02632 8-3-15 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply-❑ he 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 400 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 ❑ M Liquid depth in masmi is less than 5"below invert or available volume is less than Y2 day flow oOl7" t5ins•3113 Title 5 official Irepeclion Form:Subsurface Sewage Disposal System-Page 4 of 17 Aug 04 15 10:31 p p,5 Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name - information is required for every Centervdie AM 02632 8-3-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable 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 arrtrrronia nitrogen and nitrate nitrogen is equal to or less than 5 pptm, 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 farge 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 I I 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. 15ins W13 Title 5 official inspection Fonn:Subsurface Sewage Disposal System•Page 5 of 17 Aug 04 15 10:31 p p.6 Commonwealth of Massachusetts - Title 5 official Inspection Form a - col Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner owner's Name information required for every Centerville MA 02632 6-3-15 page. Cityrrown 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: 5' 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 NIA) ❑ 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 sepfis2mk manholes uncovered, opened, and the interior stftm4ank inspected for the condition of the baftww tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Il 0 Was the facility owner(and occupants if different from owner)provided with information on the proper maintenances 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)131 D CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Aug 04 15 10:31p p•7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville MA 02632 8-3-75 page. Cityrrown State Zip Code Date of inspection- D. System Information Description: The system is two block c pools and a pit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?.(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2013-62,000Gals Detail: 2014-70,000 Galls Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design Now(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: 151ns•3/13 Tille 50rfidal Inspedlon Form:Subsurface Sewage Disposal System-Pege 7 of 17 Aug 04 1510:32p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman _ Owner Owner's Name required foe Ceritervill'e MA 02632 8-3-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 400 Gal. gallons How was quantity pumped determined? Pump Truck Reason for pumping: Part of inspection-c pool Type of System: ® soil absorption system ® cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ lnnovative/Altemative 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DFP approval. ❑ Other(describe): t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Aug 04 1510:32p p,9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centervifle MA 02632 8-3-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Two C. Pools NA Pit 2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30" 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.): Pipeing is 4" PVC and Tile. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y ❑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: Sludge dep th: pth. 15ins•3113 Title 5 Official Inspection Form:SUI)SWaW Sewage DISpDSa1 System•Page 9 9f 17 Aug 04 15 10:32p p.10 Commonwealth of Massachusetts Ij Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane _ Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville MA 02632 8-3-15 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 - 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.): 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-3113 Tine 5 Otficiel Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Aug 04 15 10:33p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments . 49 Bacon Lane Property Address Michele Hardeman Owner Owners Name information is required for every Centerville MA 02632 8-3-15 page. CitylTown State Zip Code Dale of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: -- Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurraos Sewage Disposal System-page 11 Off7 Aug 041510:33p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is CeritENfNE' required for every WA 02632 8-3-15 page. d7i own 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 No Box 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.): 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: (Sins-3/13 Title 5 Official hspection Forth;Subsurface Sewage Disposal System Page 12 of 17 Aug 04 15 10:33p p.13 Commonwealth of Massachusetts . Title 5 Official Inspection Form v Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owners Name information required for every CerttervUle WA 02632 8-3-15 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: ❑ innovativelaltemative system Typeiname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a old block c pool and pit. C. Pool is 7'deep block w/steel cover at 2",pool dry. Pit is 1000 Gal precast. Pit at 38"below grade w/cover at 18". Pit is clean and dry,walls like new. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth-top of liquid to inlet invert 38" Depth of solids layer ti" Depth of scum layer 1" Dimensions of cesspool T Deep Materials of construction Block Indication of groundwater infiow ❑ Yes ® No 15ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13of 17 Aug 041510:34p p.14 Commonwealth of Massachusetts -- Title 5 Official Inspection Form ;11 J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information required for every CerttervUlte MA 02632 8-3-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Mairr peat is block w/sheet cover 8 cement cover at 217. 2'water in pool. One line w/no tee. Two outlets both wltee's. 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.): !Sins•3/13 TBIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Aug 04 1510:34p p.15 Commonwealth of Massachusetts Title 5 Official inspection norm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Outer owners Name iequiredifore Centerville MA 02632 8-3-15 required for every _ -_ page. Cityrrown State Zip Code Date of Inspedion D. System Information (cunt.) 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 aJJ wells within 1D0 feet. Locate where public water supply enters the building_ Check one of the boxes below: g hand-sketch in the area below ❑ drawing attached separately —i L2 l5 t -, = 32 13 3 r '`., t5ins-3113 Title 5 Offidat 6Lspecbon Forth_Subsurface Sewage Disposzl SyStern•Gage 15 D1 17 i I i Aug 041510:34p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form l" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information is required for every Centerville MA 02632 8-3-15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells d N Estimated depth to high ground water_ 25'+ 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 propertylobservation 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: Rear of property drops off 25'+_ I Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mns•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 or 17 Aug 04 1510:35p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane Property Address Michele Hardeman Owner Owner's Name information required for e very CenteryWe tL4A 02632 8-3-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C. D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 FROM :down capeg engineering inc FAX N0. :15083629880 Nov. 01 2012 09:01AM P1 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _49 Sacon Lane Property Address Andrea Rom_ Owner Owners Name Information is ill t Cenerve MA _ 02632 Aril 4 required For ,... �.:,...._ �..:�...— . . i 2012. .. every page. Cityfrown State Zip Code late of lnspe0lon 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: A. General Infarnnation When filling out forms an the computer,use 1 Inspector. only the tab key to move your Patrick M.O'Connell cursor•do not --- .. .— - ,._ .... .. _...... •- ., Name of Inspector use the return Inspector key. Septic Ins edion Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 cityfrow„ — - State— Zip Code y� 508-428-1779 S 1 12855 - — 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 El Fails (] Needs Further Evaluation by the, Local Approving Authority e r April Q,2012 Jots#1' 4�9 , ih ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority Yi3oar( of Health or DEP)within 30 days of completing this inspection. If the system is a ihared syst D or 5 IO has a design flow of 10,000 gpd or greater, the inspector and the,system owner&'hall submil;.the •,. report to the appropriate regional office of the DER The original should be sent to the systetzowne F` 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. 1G tr•11110 Title 5 otfinal 11"grAinn Fm,:Stzwdaco F,.w aV D 8008Bt System•Page t o117 FROM :down capeg engineering inc FAX NO. :15083629880 Nov. 01 2012 09:01AM P2 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C 49 Bacon Lane Property Address Andrea Ray (homer Owners Name Infornrequired is Centerville MA 02632 Aril a, 2012 required for _ .. . ... ...- .. _ -• -• -• - every page. C'rtyrTown State Zip coda` Crate of Inspection B. Certification (cunt,) Inspection Summary: Check A,B,C,D or B/always complete all of Section D A) System Passes: ® 1 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: Cesspool was pumped as part of inspection, Overflow pits were found empty with no evidence of surcharge. 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 exMtration 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 2.0 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 1,51ns•1 iJ1b TMA fs CNfcw Impadmn r orm:`utswfaw Sewpgn Dismb d SY,'tom•Pay..P.of 17 i FROM :down cape engineering inc FAX NO. :15083629880 Nov. 01 2012 09:01AM P3 Commonwealth of Massachusetts Title 5 Official Inspection Form .Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane Properly Addross Andrea Roy Owner Owner's Namur information is Centerville MA 02632 p,pril 4, 20 i 2 required for n - - $%to ;Zip Code Date of Ins eveN Cflyfrow Page. __. .. .. .-. Pec#ion . •-- B. Certification (cant.) 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 heatth, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water it ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 1. Iv10%•11MG Tales oSimmi IruNuetlon Forrll S ibsurfs6B 5rw00CWP'­1 SYSIsen•Faqu 3 M 1 I l i FROM :down capeg engineering inc FAX N0. :15083629880 Nov. 01 2012 09:01AM P4 Commonwealth of Massachusetts 3 Title S Official Inspection Form Subsurface Sewage Disposal Systom Form-Not for Voluntary Assessments _ 49 Bacon Lane — Property Address Andrea Roy m._.. Owner Owner's Name requiretion is Centerville MA 02632 _A ril 4, 2012 required for ..., _ ... �—.. ..— every page, City/t-own State Tip Code Date of Inspection— _ 8. Certification (cunt) 2. System will fail uhlass 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 fleet 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 cofiform 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: 0) 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 Q ® Discharge or pond ing 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 _ 4ina 1111n T@M 5 oRlnlal Inspea0i)FnM'SubsofawA Rcxagn Dfaposal Sya1ej11•Pap 4 of 17 FROM :down capeg engineering inc FAX N0. :15083629880 Nov. 01 2012 09:01AM P5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurfaco Sewage Disposal System Form-Not for Voluntary Assessments . 49 Bacon Lane :-- Propeny Address Andros_ Roy Owner Owner's Name information is Centerville _ MA 02632_ April4,2012__ - required for State Zip Cade rate of Inspection every page. Cityfrown ._B. Certification (cost.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ElAny 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, El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply wall 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 6 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form,j ® 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 [] p the systern is within 400 feet of a surface drinking water supply © ,El 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. Title 50rrie wl fn.pwWoil Form:Subsurlae:SBWBor-1N%W881 Systen•Pego 5 ul 17 1SinB•11110 FROM :down cape engineering inc FAX NO. :15083629860 Nov. 01 2012 09:02AM P6 Commonwealths of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane — ip, Property Andrea Roy Owner Owner's Name information is Centerville MA 02632 aril 4, 2012 required for —._._ _ ... - •-•--- _ -. ...... _.. every page. Cityrrown _ 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 NIA) ❑. ® 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 ® El 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: 0 p 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: N/A 3 _ Number of bedrooms(design); Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): tSina•71/10 Tpl6',()ffidai Inrp,-Aim Fom sattsurre seweM fNaposal System PSge 6 of 17 FROM :down cape engineering inc FAX NO. :15083629860 Nov. 01 2012 09:02AN P7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments }z 4e Bacon Lane Property Address Andrea Ro Owner Owner's Name information is Centerville MA _02632 April 4, 2012 required for _ every page. City/Town State Zip Code Date of Inspection .- D, System Information Description: No design standards for cesspools,any Changes in flow(adding bedrooms will require an upgrade_ 0 Number of current residents: [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)): Detail: Sump pump? ❑ Yes No Unknown Last date of occupancy: note Commercial industrial Flow Conditions: Type of Establishment: - -- Design flow(based on 310 CMR 15.203): GSllpns per day(90) Basis of design flow(seats/persons/sq.ft., etc.); — -- "— Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanikary waste discharged to the Title 5 system? ❑ Yes © Nn Water meter readings, if available: --' fF.lnx•11110 llf o 5 ofriciel Mpr dim ra jn.S111ravfam sewer.Oisly I Spi m•PNL*7 rt 17 FROM :down cape engineering inc FAX NO. :15083629880 Nov. 01 2012 09:02AN Pe Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 49 Bacon Lane . ._. _ _ Property Address Andrea Roy _.— Ownar Owners Name inf Is raquIrad Centerville MA 02632 April 4, 20t 2 ulred for fo •• - -- -- - every page City/Town _ State zip Codo [Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Cesspool last pumped_10 years.aq2._ `__. „ Was system pumped as part of the inspection? Yes No If yes,volume pumped: Unknown gallons How was quantity pumped determined? Reason for pumping: Cesspool inspection 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ine•19l10 Tft E Official imprcliun rorm:$ub:a,daca S9wFlgn Dispoeal SYslrn•P%e a of 17 FROM :down cape engineering inc FAX NO. :153e3629880 Nov. 01 2012 09:02AM P9 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane Property Address Andrea Roy... -- Owner Owners Name - information Is Centerville 02632_ April 4,2012 _ required for State Zip Code Date of Inspection every page. City/Town _ D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: Unknown _. __....Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: Meet Material of construction: ❑cast iron 44 PVC ❑other(explain): - Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage,etc.): Septle Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Sludge depth: l'Itle 5 africialIr rpediori norm:St b6Vdace SOWage'li-.pUBRI Sy'aem•Pape 5 of 17 151nx-11110 r - FROM ;down cape engineering inc FAX NO. :15083629880 Nova 01 2012 09:02AN P10 Commonwealth of Massachusetts Title 5 official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane — Property Address Owner Owner's Name -- Inf rmabon for le reguituredred Centerville MA 02632 April 4, 2p12 — -.. —.... —... .. every page, C yl town _ State Zip Cade Date of Inspection D. System Information (cant.) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle — --- 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 -- — Mow 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.): Crease Trap(locate on site plan): Depth below grade: feat Material of construction: El concrete U metal El 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 t5tns 11f10 TAW_5 0ftal I:WPBCtm Fwn1:Suhmrfa,.ro Sgwa9e DiepCaal System-Page 10 017 FRO11 :down cape engineering inc FAX NO. :15083629880 Nov. 01 2012 09:03AM P11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane _ — �P�Y Address Andrea Rom_......._._ _ Owner Owners Name requiflon Is rldfo required Centerville _ MA 02632 _ aril 4,2012 rered for every page. City(rown M State Zp Code Date of inspection D. System Information (cunt.) 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 [r] polyethylene ❑other(explain): Dimensions: - — Capacity: Design Flow: gallons per day Alarm present (] Yes ❑ No Alarm level: - FUarm In working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches.etc.): Attach copy of current pumping contract(required), Is copy attached? ❑ Yes ❑ No i t5ne•91i�1 1ftlr 50rritasl Mpwion forth Subs ffaaq Sewage Dlsi=l Spstmh PRgL'11 a 17 FROM :down cape engineering inc FAX NO. :15083629880 Nov. 01 2012 09:03AM P12 Commonwealth of MassaChusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bacon Lane _ Property Address Andrea Roy Owner Owners Name information ogt irod fo is Centerville MA 02632 A rip 14, 201 tnqulrod for _ ... .. ._. _ .. —_. ..... � . .. _. every page. Chy town - State Zip Code _ pate of It1s ction D. System Information (cunt.) 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.): Pump Chamber(locate on site plan): Pumps in working order: © Yes No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: I r5ins•1-110 Tab 5 Offog rnsp"ioi r•urm:s,4hnAacc sewtno mammal System•pngn 12 of 17 FROM .:down cape engineering inc FAX NO. :15083629880 Nov. 01 2012 09:03AM P13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon Lane _ -— Property Address Andrea ROY Owner Owner's Name information is Centerville MA 02632 _ _April 4, 2012 — required for - - State Zid Cede Date of Inspection ovary pa", Cdy/�owtl D. System Information (cont.) Type: E] leaching pits number: — 0 leaching chambers number: — — ❑ leaching galleries number: - ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ® overflow cesspool number. Two sx6 pits ❑ innovativelaltemative system Type/name of technology: -- - Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Overflow pits were em at.time of inspection, No evidence of surcharge or saturation found. - Cesspools(cesspool must be pumped as part of inspection)(locate on site plan). One wt 2 overflows. _ Number and configuration — 4 -- Depth-top of liquid to inlet invert 12" Depth of solids layer a". .- -... _... — Depth of SCUM layer BX6 Dimensions of cesspool Brick Materials of construction Indication of groundwater inflow ❑ Yes No Tills F C)Riciel If1��tlicm FCTRI::ubduM��`Svw1u,�=��wxni ryyzlan�l'Papa 7J ur 17 1��9z-11/10 i FROM• :down cape engineering inc FAX NO. :15083629e8O Nov. 01 2012 09:03AM P14 Commonwealth of MaSSachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Bacon 1_ane Property Address Andrea Ray_ Owner owner's NKne - r"uir dfo is Centerville MA 02632 _ Aril4, 2012 r+aquired for cityrrown — State Zip Code Date of Inspection every page. .. D. System lnfolrmation (cost.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool was structurally sound and soils were normal. Cesspool had 30"of water and solids with no signs of surCllarge. Recommend annual Um in If house is occupied year-round. 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.): MUr-•11/16 Tine:.ofricial inspr.mi"n roan:ytRlsurfw*U*W..Oi pu6al By;l m-Pa)f@ 14 of 17 FROM :down cape engineering inc FAX NO. :15083629880 Nov. 01 2012 09:03AM P15 Commonwealth of Massachusetts - Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Bacon Lane — — — Property Address.. --- Andrea Roy — .. _ _ -- .--,•- Owner Owner 5 Name information is Centerville MA 02632 April 4, 2012 required for _ Stele Zip Code Date of 6ispeoflUn rown ®very peas. Ci tY D. System Information (coat.) 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 I r J r l / J 1 r 1 r J r r I 1 I / . , � . , ♦ , ♦ , , ♦ � ♦ Back \1,/♦J`,,r`J�lti`/\, / ! ! J r r r r / I 1 / r , / 1 J r , J r ,r♦J♦J♦J\/�J\r♦J♦!\ J r / , / J , r r r J J ! Yard Cover at grade 22 4 31 f FROM• :down cape engineering inc FAX NO. :15083629880 Nov. 01 2012 09:03AN P16 c Commonwealth of MassaChusOtts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 49 Bacon Lane Property Address Andrea RoY.. Owner Owner's Name it nrmation is MA 02632 Rril 4, 2012_ ro dredfor Centerville q Skate Xtp Code Date of Inspection every page. cityrrown _ _ D. System Information (conk.) Site Exam: Check Slope Surface water ® Check cellar ® Shallow wells 20+ Estimated depth to high ground water'. 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; Low area at rear of prope with na standing water is considerably 10Ver than_ items. Before filing this Inspection Report, please see Report Completeness Checklist on next page, yjuR s orricio Irgmaion FMI:SLMOSCS Sc*ape UISPL'Sl Sy=tern•PW 16 of 1'] 16iM3.11110 FROM,:down cape engineering inc FAX NO. :15083629860 Nov. 01 2012 09:03AM P17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 49 Bacon Lane - - — Property Address - - Andrea R -- — Owner Owner's Name ron is equir Centerville MA 02632 rii 4,�2012 _ requiredd for '— State Zip Coda bate of Inspection every page. City/Town T E. Report Completeness Checklist ® Inspection Summary: A, D, C, D,or E checked t9 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 Title 5 Of`rai81 irapoatiors Form:Subm Wa smave ooposal sYetpm•Pape IV of 17 (sins•1111V No.- .� ..... �..+ . Fss. SQ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 1.G1 OF.......awl ..,C ,Ic....................... Apptiration for Uiiplo sal Works Tnnstrnrtilan rawit Application is hereby made for a Permit to Construct ( ) or Repair (L} an Individual Sewage Disposal System at ... . ... r1.... .................................... - ....... ................ a �oca/t ipo_nw-ezddress � .................................. ............. o/r �t No . - - - ------ Ad ress _ a c ...........1% cmjl&----------------------------- ---------- Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ............................ No. of ersons......_..............._._._. Showers — yp g p ( ) Cafeteria ( ) a' Other fixtures ------------ ................................. Design Flow............................................gallons per,person per day. Total daily flow_.........................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------_-------- Diameter...._............... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil.................... �........ !!d --------------------------•---------••.-•-•-----•------- ------..--•• W x •--•-•-•-•-•.......................••••----••---------------------••------------•--•-------•-------•---•--•--••---------------••--------•......-- U Nature of Repairs or Alterations—Answer when applicable..-----.) /-_ "-_9LL ._. .� .----------•--- --------------------------------------------------•---------------------•--•---•-------.............----••------------=--------------------------------------•---•--•--•--••-••----------.........-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of A ITS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued b the ard ealth. Sin - -•- ----•- . .... t/...... . . . . ... Date Application Approved By.............. :. .....---- ..................--•.---- Date Application Disapproved for the following reasons:.............................................................................................................. - ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued_....................................................... Date L •-•-— a FEB.... a ......4(4+6 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . . ......OF.......: ! `. .���`.'b,�.'r�-�.•........................ App irFation for Mipasal .lVarkii Towitrurtion pamit Application is hereby made for a Permit to Construct ( ) or Repair (4-41 an Individual Sewage Disposal System at: za ocatton Add re � y J -Z— ' 4 �Owngr Address w .� fi �t .: cam f V a Installer '� Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................. .. .Expans on Attic ( ) Garbage Grinder ( ) �-, Other—T e of Building No. of persons............................ Showers — Cafeteria a+ Other fixtures -----••-----••------------•---•. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.:',�........_....._ Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 7T Test Pit No. 2.........._.....minutes per inch Depth of Test Pit.................•.. Depth to ground water........................ Pd -- -+-----------•-- ::-- ----------- •------- --...... •--- --- •-------------------------------- •....... .-------... Description of Soil = ............r ........ U -------•--•----•---••-•-----••••-•••--.....•-•••--•-------•••-••------------•-----••-----------•----•-------•---•-•-••-•••-----•-------•----------------•-•--•--•-•-----------------•----•----•-•-----•. W •• •----••-------------------•-••-•-•------------------•-•-•-------•-----•-------•---------••----••------- --•--•----•----------------•------•----------------•-••-••-----••------•---•••---•---••••---- x - VNature of Repairs or Alterations—Answer when applicable...._..._... ........ f- '_ ._. r. !'._'______________________________________ ----------------------------•---...-•--------------•-----------•----------------------...........-•--------------------------------------------------•---•--••••-•-•-----•-••••--•------•-•••••-••----•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE. p 5 of the State Sanitary 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. ed— ,� f t , - /- - •1 tD o Application Approved By.......-- -----------------•---•-- F .................... Da.-e.............. Dat Application Disapproved for the following reasons:--------•-•-------•--------••--•----------------•--•--•-•--------•-•--------•---•------------•-••-•••------•---- -----------------------------•----•----.....-----.....---•-•-•---•--•--------------.......-•---------------------•••-•-••-•------••-•---•-•-------------------------------•----•...---••----•--........_ _ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF F HEALTH ............. OF....... ................................ (Intifiratr of fIlampliFanrr THIS IS TO.,,CERTIFY, That the Individual„.Sewage Disposal System constructed ( ) or Repaired ( }-- r o f f � �z '_�---Instally 1 at__l�1.-•-r^"A 3 -'-•!' ' ... --- . .. ` -•--•-----------------------•-----------••----------...........::. �r ---------------- has been installed in accordance with the provisions of TI"' r j f The State Sanitary Code as described in the application for Disposal Works Construction Permit No. r _ ............ dated________________________________________________ s THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL.FUNCTION SAT FAC ORY. r--, DATE.---•--......•...............•--•-•.... �}' d Inspector.............. ... THE COMMONWEALTH OF MASSACHUSETTS _,r BOARD OF HEALTH /No......................... FEE.............:.::. . �i��rr�ttl nrk� T.�n��railari ,,rani# Permission is hereby granted....._­-`= '� «�� `G ._ K.,� ........................... to Construct ( �.) or Repair (�y an Indio dual Sewage Disposal System r atNo.- 9 r'✓ lJ1, d .......... "--------•--------•-----------------------------------•--- Street as shown on the application for Disposal �- ......... ., Works Construction Permit No..................... Dated.....•.__.__._......__.................... -�"-' = •/�v� -• �Ke.lt -------------------•--•---........-•---. /�! o DATE.----•---....9 - FORM 1255 HOBBS & WARREN, INC., PUBLISHERS LO AT ON � StWAGE PERMIT NO. VILLAGE � �7 � p 6q III INSTALLER'S NAME i ADDRESS i t .i U I L D E R OR OWNER z . A, T ISSUED r- - DATE PERMI � /� / T�� - DATE COMPLIANCE - ISSUED. r1` ------------- S F} I wry it r 1 10'-V COVERED VERANDA T-r ADDIT .14•EXPOSED AGGREGATE SLAB TO MATCH EXISTING POOL DECK � 17 L/ O 5• 4 ijI1iIII tjIItII1 IiIIIII IIIIIIt 1IjII1II 1tjIt1II I1tII1I I1II1I a FAMILY ROOM i� �rss�aa-. •�;\\fJtI zaQ4,b§ 8�:wttQ� s i 3 L N: TNl UP ;3 Vtu s-i LIVING 4OM WN �. 4, ONBOTSDES oo�-BA RION ----L — u- 1J — BOTH 1 2 l4>11 m D (4 LSE DOW II II II 4.E, f l I I i t 3-B e•-1 DINING ROOM z II !I II E \ ENTRY__—PORCH___ ~\•\ i�• i i i l l \ BATHROOM _ y \II 1 o\ xieex4uxs I 3 B •�. p -i erar.a• t OVr ®EACN O ® REMOVE EXISTiN6 ODOR LDCA PRERY BFRANE ANDRE- EAS DW S.. INgCAtEO. a D.W. BEDROOM#3 o1srG. 3• �� d RF�F. o NEW LA OV11ET1: �STUDY __L..._ ' 3. Y m f0.01 •KITCHEN 1 " 'I Q O 1e zB x — 1.-, Li" 1 d / -1 '-i } '�., 1•'1 4 0'-t"� �6 � I d 15T FLOOR PLAN v11 ' RD D AIIIII01 NO, REVISION DATE 1 ST FLOOR PLAN CLIENT: McGrath Residence 49 Bacon Lane Centerville MA 02632 SCALE: 1/8"= 1'-0" TITLE: 1st FLOOR EXISTING HOUSE&ADDITION PROGRESS PLAN DATE:OCTOBER 5, 2012 MICHAELA.JIMERSON A.I.A. ARCHITECTURE&INTERIORS 193 Horseshoe Lane Centerville,MA.02632 5087754264 majarch(aalmcast.net a V KJ 'I S,HL 30-31C 9aLiMR00RiUC M sUT.. B ❑ I H.Ht.83- eJ 8. el H 32-3(d' E%ISTWG DODR RELOCATEDM ,y C' NNEN5TOR. L✓ NEW PART.TTION. \. 1 ,"Z fWX BY �.»-8.�........ ......... .�.. I O I. (2)NEWS'PLYWOOD 1 WITH ROD O CLDSEFS WITH y CairgNl64'� a•Wx NTI[SffH. 9 •\ Ceirg.HL"Ir F rq MASTER BEDROOM �m jjgggg__RX EMSTING LOD�E. Nl� Fi53Vi ec Ros.mDD \ / Cw �Z SCNEWS.F'LLANDRE-FINISH '\ AS NECESSARY. ON 8,-�• �• celI'g.HL8 cmr9.HL 1. iIL �� AY ROOM _._. - 1 BEDROOM#2 / ` 3; ®I ❑ 0 t�y ( CeR9.W.90-SHB' CeTg,H490.7(8 a wiu ' 1 Br �r�38-3 - ------- ------ � A. 02 NO. REVISION DATE a CLIENT: McGrath Residence 49 Bacon Lane Centerville MA 02632 SCALE: 1/8"= 1'-0" TITLE:2nd FLOOR PLAN FOR PRICINGT DATE:OCTOBER 8,2012 MICHAEL A..IIMERSON A.I.A. ARCHITECTURE&INTERIORS 193 Horseshoe Lane Centerville,MA.02632 5087754264 majarch@comcast.net Roue 28 I Rood �o y� Q coo Locus cudder y i o m orseshoe Ln i $ zoda �y O `o� Main Road St' or) B each 8.99 LOCUS MAP SCALE 1"=2000'f 6 ASSESSORS MAP 207 PARCEL 19 LOCUS IS WITHIN FEMA FLOOD ZONE C BENCHMARK: TOP STONE DATUM: APPROX. NGVD BOUND EL. 50.7' SEPTIC SYSTEM AS PER INSPECTION REPORTS DATED MAY 12, 2004 & 4/4/12 EDGE PAVEMENT ury CON '34. x-49.25 LANE ZONING SUMMARY \ 49.90 x \ x 1 49.51 PROPOSED� ZONING DISTRICT: RD-1 DISTRICT CANTILEVERED ROOF x mkt 60 ,fig--7-p OVERHANG;" MIN. LOT SIZE 43,560 SF x 49.49 53 C48zF_" MIN. LOT FRONTAGE 20' x 49.49 9. I \, 49.79 MIN. LOT WIDTH 125' CONC. PAD b x 49. $4 4��4 MIN. FRONT SETBACK 30, 67 Ca?ARBOR v b, M x 50.61 --x 49.81 49.97 MIN. SIDE SETBACK 10 49.67 49.74 k N N l c 449 6 MIN. REAR SETBACK 10' x 4 .49 ' I l - 50.21 98 EXISTING 5 f CONC PAD v �Q� 50.74 94 CONCRETE PAD p,21 0_00 50.18 SITE IS LOCATED WITHIN RESOURCE Co ELEV. 50.0' / / PROTECTION OVERLAY ESTUARINE 0 1 STONE / PROTECTION AND AP DISTRICTS k ��� ' x\50.16 DRIVE EXISTING 49.97 2 FIRST FL. EL. 52J' 5' 7 \ POOL 01 .34 4 40 08 EXISTING 50.29 \x�`0 2� 49.92 �. x 49.03 DWELLING 'max 50.36 REFERENCES 9.11 86 a 87 TOP FNDN. = 52.3' 4g 49.63 x 48.78 .46 CTF. 197115 LCP 20895-A SHED X �_x3g 9 PL. BK. 521 PG. 242 GAS POOL PAD CORNER ELEV. 49.6 ,�p,'L METf R o PROPOSED] EXIST. PIT � 3 ADDITION/PENOVATION AREA (J 4 .1 ON CRAWL`SPACE MAIN CESSPOOL PROPOSED 24" THICK FOUNDATION THIS AREA TO MA114TAIN MIN. 10' To INSIDE x 46.72 CJ� r� WALL 91,0p. 1000 GAL LP x47. 9 I i 99.61' SITE PLAN R OF 49 BACON LANE CENTERVILLE off 508-362-4541 PREPARED FOR fax 508-362-9880 �% OF r �<HOFM ti rip�H MggS q'SS � downcape.com © a� � DA lEL 9c�' PETER McGRATH { JAivzELA. N , ROW cage engiaeefing2 iac. CIAO �4 ` OJ/,LA 2 No.40980 , OCTOBER 17, 2012 civil engineers land surveyors °�F s\o , , 939 Main Street ( R to 6A) . / Scale: 1 = 20 YARMOU THPOR T MA 02675 12-260 f DATE DANIEL A. OJALA, P.E., P.L.S. 0 10 20 30 40 50 FEET i