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0032 BELDAN LANE - Health
A 4 32 Beldan Centerville '•" A = l89 — 03 l' 015 -.� .' r I �11dA �ra�, UPC 12534 o.2.153L0 (@. - t a 1 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH L✓^.J...I.........OF..... .��../� ox .� ...�.---•--------------•----•---•----•---- Appliration for Uhipwia1 Works Tomitrnrtinn ramit QJS� Application is hereby made,for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ff System at: Za72';'�_1-� - �-0 ten/ �,✓� Loc 'on Addr s ror Lot No. - Owner -- Address �............................................ ......... ! '? �C Installer Address PQ U Type of Building ..y Size Lot. 9`$._____Sq. feet Dwelling—No. of Bedrooms----0..................................Expansion Attic ( ) Garbage Grinder (NC) '4 Other—Type e of Building No. of ersons---------------------------- Showers — Cafeteria a YP g P ( ) ( ) Q' Other fixtures ------------------------------- -- W Design Flow............................................gallons per person per day. Total daily flow.-_33--.------------.-.-.-.--------gallons. WSeptic Tank—Liquid capacity.1siv_10--gallons Length-----Z------- 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 (y) Dosing tank S ) ///. `" Percolation Test Results Performed by-----&—lWZ k�.. -_.. ie_ff41 --........ Date....__GL---7--_ ___.._--.... Test Pit No. I A"rs-r......minutes per inch Depth of Test Pit...........t------- Depth to ground water--- ..... Test Pit,No. 2_��_.jd!:-9.minutes per inch Depth of Test Pit.....Al.......... Depth to ground water- Description of Soil 1.d?- ....................... ......... ------.................... --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-...••••- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ....................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 1?: L y g g p y 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has be issued by the b ' rd of health. /� ned --- �__.. ___�'__ .. �� = � A.. �/ iDat Application Approved By........... -----.- ............ ��...................... L" v-------- !' ate Application Disapproved for the following reasons-------------------------------------------------------------------------------•-------------------------------- ----••-•--••-----------------•---....---------------------------------------------------•-----------••-•.•-------•-----•-•-•••••-----•--•--•-------•-----•--•--------•--•-•-----•-----••--••------_----- Date PermitNo......................................................... Issued--.7.__• Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (, - OF.....9 ............................................. Appliratinn for Disposal Works Tons rnrtinn Prrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............... Loc ion Add ess or Lot No. / r'/IFP lfd / �f / Owner �;, Address - ........ •..------ ....---•.............•-•------.........---- Installer Address r7 QType of Building Size Lot__4_-`-�.................Sq. feet U Dwelling—No. of Bedrooms____ ___ ___________________•-_________Expansion Attic ( ) Garbage Grinder (�''�� aOther—Type of Building .:.......................... No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures ---------------------------••••. . • •- W Design Flow.............................................gallons per person per day. Total daily flow---T3.0.............................gallons. WSeptic Tank—Liquid capacltylo-k3 _.gallons Length:--.t__.____ Width----Y-------- 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.....4`64-/ 'Ak--. ........... Date..... _/.__`___/...... ............. Test Pit No. 4Pfr......minutes per inch Depth of Test Pit_` --.-I-__-____•. Depth to ground water_ ¢".i?-...... (s, Test Pit No. 2 24!-minutes per inch Depth of Test Pit---/;............ Depth to ground water- .z/rCa-.1.1 r� D Description of Soil...•-� l �wN� -Il��f�i ... /' G� . ---•--...---- c, x ----------------------------------------------------------------------------------------------------------------------- --------•--••-•-...........••••--••----•-•••••---------•------•-•-..........---- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE,• y g g p y of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ' - .'�`r1'____--------••---•--------- ....... Dates Application Approved By..... -•-4•� "': . � �..._____�' i___'fi'............................ I Date Application Disapproved for the following reasons:--•----••••••---••-•----••--•--•-•-••--•-•--•--••-•---••----••-•-•-------------•-•-----•----•-•-•-•••-...._..... ---------------------------••----•--------------------------•-------------•------------------------......---•-•--••-•••--•--•--•--------•-•-•---•-----------------•-----------•-----•-----•-•-•-------•- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .�t!�................OF...... j �JfN . '.............. ......................... %Crr$ifiratr of Tontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed sK) or Repaired ( ) by....................(sa z.,y../.t-�°r�' .........................Installez..-- ------- -----------------............-----•--------------•----•---•-•---•-----•------................. / � �.. J C at. /'= S P�1�"�1... y �'�'i"o`.fc ( ,i --- -----------------------•------------------------------------------------------- has been installed in accordance with the provisions of TITL: j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__.160• _1__1_.!--_-•-___...... da.ted-.---------------------- ....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE SYSTEM V►/ LL. FUNCTION SATISFACTORY. DATE.... ..................................•�Z - .:....... Inspector..... . ..... . THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF,' HE}A�LTH rl•�y ............OF......I,;l.Sn.tN:�I!� NoR.. . . .V..�... FEE........................ Disposal Mork vnstrnrtion rrntit Permission is hereby granted ?f� . ....•.......I.''.........------•----------------------------------------------------------•-----•----..... to Construct ) or Repair ( ) n I i.ual Sewage Disposal System . ----•-• . -•--•---•-------••--•-••......•---•---......at No........................ r-=.`-1.5._.. !�.P/ -�3rv� ,. �- �'.,0 'i'v� ,?' �z Street J as shown on the application for Disposal Works Construction Perini No..................... Dated_. -----•--- -- -•-•-...---•-•-•••-•... DATE............ 7 - --- -------------- Board of Healt FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 3; ' IV '7' 'ErIlrNeR 7AI, 0 e e.5-4--P 77 C 7-A Al/< 20 R7. Mllv., 'ei 1--6q&Ae11VG 'PI r AN&--MO Rd-= '7",N A/V-Ai� REID J&V :6rAAA=. �,A p4. SWA/-4 4�fA - COAeCA&TO COV4 WW. P/7'CH A8".PsR r Mllv. *MADE cc)k,.—,Cr CLEAN -TA/V X-) Al� &A CA-)=I Z L *LAYER IRON p/pz P v 1 7, 4"CAST OF Mb 17 0 /000 6 A 1- W14 5 HAFO 5701V,-- DIST SEPTIC TANK Aso, BOX p cr/Vw A94L-,-7-.AV • • WASHED STONE P17 OR 50VIV. IAIVAeAT &r4.=i1A*r1.0,V5 -r. FN,41611. 'Fr (5i--'7XWZ/4-A-7-j40,A�) INLET SEPTIC TANK -5`7,�r-+ ,r F 0M. OUTLET SEPTIC 7-AN.A< J'S .7- F7- --Ilr TABLE IAIZ�=7*D157HI4041TION BOX Y4,"9 =;r S-EC771ON 0.=- GROUND WA7. OUrZE7D-157'Rlojrr1o1v BOX S-4 f5- 1=7 I-EACH1lVCr.,oc:lV7- 41L.ATIDAI • 4,EACH11V4rw 01T 7A8 olmelvsl 0 Al A DR516N CNITAERIA TCALE 4 a 6 FT. 10 INK-N510) •NUMBER OF BEDROOMS G,4 RdA.GEP1SP05A I- 41N I r SOIL TEST'' Z-0c7l so/41. rD TA 4 EST/MATED F=1-0 AIV 3 S 0 L. TEST *I SOIL r A141148E 4-04CH INC, 0/r.S ore,4,-- v sd-r- ' —4- - . OA 7E OR, SO/L TEST- SIDE LA--ACHING Al-EAC R17' 5-?'S47 F7 Lt RESULTS it/1TNESSED,; ByR • • �u 490r7'0Af 4,94CHIAI& PER Plr 7 SQ. -M77. Z-OA.m - AERCOZAWO" RATE,*/ LDS All"IINCH 7-07A4 4eACH11y& AREA SQ. -F77- AMVC0,LA'rl0lV RATE JkZ i4 N MIA1.11MCH W. F7. -IV6 c F Z73 4s, • RCBER.� P. cn BUNIKIS 'k j? A to �T, -,* tle z I -i-e L p No.22162 0ELOREDGE C Z /ST -Sr.- t. -, -:7"V OUI �F , ;4 57 MA -eo r ar/vc V;, ONAL vo,�a Atov/vg:�-�iv,-4 7 k A G41 e 05 /VO O. 4=' Z21 A-7 � F C r SG.�3 ° Z ISv o n_38io �, c ,� o �, .�.Q~. ice.-� �'•' i _ � • �� 'fin -1� `,� ) - 7 00°G JI a , ve N / a ROBERT t P. R, A—' M 0 I _ BUNIKIS. �F S6 ( N " o pNo.22162 0"Q j `-.� S'ONAL Ede t E'XIST!NG SPOT ELEVATION 0,0 GERTIFIE1) PLOT P; AN _E X 5 0 _ ---- --_- _— - ;f1Ny:SHED '`SPOT ELE N 4 0l ` LOT /.S" �8c—L.L��f il/ G�it/� ' N' S H L P .CONTOUR : 0 IN APPROvED BEARD OF HEALTH o �' tL,ATE AGENT SCALE . •� �4� .' G E �E'LREDGE ENGIrVEER/NG CO. ING' CLIENT ; I CERTIFY THAT THE YROPOSED ? r TEREt� REGISTERED`; JOB N0. 7� U d� BUILDING SHAWN, C'ry THIS - Ptl- AN o Cty1L. .' LAND CONFORMS TO THE ZONING . L`AWS.:., ,ENG1ryEERS,' l $URVEYOR$j DR BY ' �� OF BARNSTA L 1 , MASS _ ..._ MA;N :iT CH 8Y /fl HYANNIS VAS.:, � � SHEET f OF ... ._ _ DATE REG. LAND SURVEYOR ' LOCATION SEWAGE PERMIT NO. VILLAGE o� ol -S INSTALLER'S NAME i ADDRESS GUILDER OR OWNER cc-,-'re DATE PER IT ISSUED DATE COMPLIANCE ISSUED ��� �_ .� �- � `� r ,, __ -� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 32 Beldan Lane �p Property Address Michael Perry V Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 9 page. City/Town State Zip Code Date of Inspection IV A Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection VkA Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 3/10/2016 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 4 age' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 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: The dwelling located at 32 Beldan Lane Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a precast 1000 gallon leach pit. The system was found to be in proper working condition at the time of inspection. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 M 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Beldan Lane Property Address Michael Perry Owner Owners Name information is required for every Centerville Ma 02632 3/10/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 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 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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: 2014= 36,000 total = 98 gpd 2015=43,000 total = 118 gpd Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 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 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 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: original system installed 1980 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 4" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection F rm 0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 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 3" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. Access covers are on risers within 6"of grade. 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): OilDepth 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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•3/13 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 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 x 1000 gals ❑ 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.): At time of inspection the leach pit was found to have 2'of standing water with a stain line 1.5' higher. Cover is down 2.5' below grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. Cityrrown 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.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately TA,k,V t /a-z 3'9 3 �2 27 011 D.i3r>x (_&vkc rt p rT A-y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. CityrTown 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: 12'+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 32 Beldan Lane Property Address Michael Perry Owner Owner's Name information is required for every Centerville Ma 02632 3/10/2016 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Feb. 29. 2C16 3: 15PM No. 2863 P. 1 05/15/2013 WICn 8156 arI 508 420 0875 W. laaveia x9 Qaterviile "zk Stanley R00I/017 Gornmonweaith of Mauxhuwfts .`Title 5 Officla-1 Inspection Form Subswfaoe Sewage Disposal System Form-Not for Voluntary Assessments 32 Beklan Lane o5 Property Address - .Charles C.Case Jr Acvaer Ot�te►'sWarr►e ,..-...�.....�,.-...—._.._..��.�..,,.....�... m...,..,.-..�,� _., kft required atbn�° GSntervllle IUIB 02.632 4111/2-013 CD required for every ..,....,. ,. page. Glty/f�wn 5tRte. 9p Cade Date'arinspedion Inspection results must be submitted on thl$form.Inspection forms may not ba altered in ally wsy,please Bbt-completGnesa cheekliM at the-ghd of the-form. hnporttf v+me7r A. Gentirai Information�ping out farms on the computer, vs891dythdietr 1, ]pspecfor: key to rnave your Cursor-do not Sean M.Jones use the relrun keY. Ne"of h 6pertor S.1Uf_lones 7ftI6V 5 6c to gs�gn company Nam0 — 74 Poldan Ln. CampRoy'Adaaw Centerville Ma 02632 Cily/roWn Suite Zrp Code — 774-248AB60 ismjqpq4Ue5Amal1corn � 814522 �y_ 'felepfloaptdumher Llcerisa.r�mber B. Certification I oerhfythat I have personally inspected the sewage dispashl system at this address and that ft- Information reported below is true,accurate and complete as crf the Limb of the.ihspectian.The Inspection vms petformad baaad on my baling and experience In the proper function and mamnance-of on site sewage-diWsal sy6tems..1 ern a DEP approved system inspector purse_ant to Soctton 13.Z 40 of -Title r;(a14 GMR 9b.1t00).The system Basses (j Conditionally passes d Fa1ts [ Nseds Further Evaluation by the L%sl Approving Authority 4J1112013 The system inspector shall submit et copy of this Inspection report to the Approving Authority(Board- of Health or DEP)vAlhin 30 days of completing this inspection.ifthe system is a$hared system or has a design flow of 10,000 gpd or preaitor,the inspector and-the-system owner shail-submit'the report to the appropriate regional offlce of ftie DER TWorlginai should be sent to the system owner and copies sent to the buyer,if applicable,and the approding authority. report only describes conditions at the time of-InWeetion and under the conditiorm of uw atthattlme.ThW-inspection does not address how'tho-systarnwO)perforin.in the Mum-under the saim,or different aondltlons of uae, d11S 1iff0 Tme51OM .MpONW Form!Subiwface&wwOb?wAd 6W-M-PAPA of17 Feb, 29, 2C16 3: 111PM k 2863 P. 2 05/15/2013 WED 8: 57 WAY 508 428 0815 W. RaveJ.s RE OsterviUe 4— Hark Stanley 12002/017 Commonwealth of Massachusetts Title 5-Official Inspection Form Subsurface Sewage bisposal System Form-Not for Voluntary Assessments 32 Beldan Lana Property Address Charles C.Case Y. Owner OWnsea NameWorm - -- - - on to taquIratfore Centerville Ma 02632 411V2013 r�g0lrsd for every pege p Code Date ofInapaution B. Certification (cont.) Inspection Summary:Chack A,B,C,D or E 1 always complete all of Section b A) System Passes: 1 have notfound any information which indicates that any of the failure criteria described In 310 CMR 16.303 or In 310 CMR 16.304 exist Any fiailure crftria not evaluated are Indicated below. Comments: The dwelling located at 32 Belden Lane Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank,distribution box and precast leaching pit.The system was found to be In proper working condition at the time of Inspec(on_ B) System,13oaditionally 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 cf Health,will pass. Gheck 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 olds or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or ext filtration 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 septa tank will pass inspeotion 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 ❑ Na(Explain below): 15ma•11110 YAIe 9 W4al I q=Aian Fay SUbmuf$Ee 8emep'8018M918yM8m•Pogo 2 of 17 Feb. 29. 2M 3: 111PM k 2863 P. 3 05/15/2013 W9D 8: 57 10AX 508 428 0815 VT. RaveiS Rs 09tervil.l,e — Mark Stanley linoo3/017 Commonwealth of Massachuse is Title 5 Official Inspection Form Subsurface sewage Disposal system corm-Not for Voluntary Assessments 32 eeldar)Lane - Property Address Charier,C,Case Jr. Owrwr Owner's Name information Is Centerville _Ma 02632 4/11/2013 required for every -�--, -- page, Mytrown 5tai® Zip Code Date of Inspection B. Certification (cont.) E i B} System Condt lonall y Passes(coot.); ❑ observation of sewage backup or break out or high static water level In the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution boar.System will pass inspectlon If(with approval of Board of Health):, ❑ broken plpe(s)are replaced ❑ Y [] N ❑ NV(Explain below): © obstruction Is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ The system required pumping more than 4 limes a year due to broken or obstructed pipe(s).The system will pass inspection it(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below); ❑ obstruction is removed ❑ Y ❑ N ❑ No(Explain below): o) Further Evaluation Is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the ward of Health in order to determine If the system is failing to protect public health, safety or the environment. 4 1. system will pass unless Board of Htalth determines In accordance with 310 CMR 13.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy Is within 50 feet of a surface water ❑ Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh 8ina.11 M o Two 5 Qlr W Napa clion ro m:$Mwd4a4%Wqp Dhp$d 5yefeol,Page 3 9617 Feb, 29. 2C16 3: 15PM k 2863 P. 05/15/2013 WED 6:58 FM 508 428 0B15 W. Rhvais RE Osterville --b Mark Stahloy 9004/017 Commonwealth of Massachusetts Title 5 Official Inspection Form subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3213eidan Lane Property Addreom Charles C.Caso Jr, Runner Owner's Name requIr dfo Is Centerville Ma_ 0262 411112013.. rgqutred for every -- p e Co rown state Zip Code Dale of lnspaoOn B. Cerpficatloin (cant.) 2. System will fal 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 60 feet of a private avatar supply well. ❑ The system has a septic tank and SAS and the SAS Is less than 100 feet but 60 feet or more from a private water supply well**. Method used to determine distance: This system passes if the web water analysis,performed at a Di=P certified laboratory,for fecal aoliform 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 bo attached to this form. 3, Other: d) System Failure Criteria Applicable to All Systems: You nQ9 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ m 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 tt afs•WIG 7ing 5 Omar lnapecft norm:8ubaafU6 so"go Grsposd S766 A•Page 4 of 17 Feb, 29, 2C16 3: 16PM1 No. 2863 P. 5 05/15/2013 WED 8: 59 FAX 508 4H 0875 W. Ravexs Rj� 0stexv;U1,e Maxk Stanley W0051017 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Dorm-Not for Voluntary Assessments 3213oldan Lane „T Property Address Charles C.Case Jr. Owner Owner's Name iarcrul r dfoilon is Centerville _ Ma 02632 4111/2013_ ra gel for every page, Cltpr['own State Zip Cade Q'dte or Inspection B. Certification (cont.) Yes No ❑ Required pumping more than et times in the last year NOrdue to clogged or obstructed pipes).Number of times pumped: ❑ t9 Any portion of the BAB,cesspool or privy Is below high ground water elevation. ❑ to Any pordon 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 ❑ I� 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 Del'certified laboratory,for fecal collform 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.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd, ® The system J&.I have determined that one or more of the above failure criteria exist w described in 310 CMR 15.303, therefore the system falls.The systern owner should contact the Board cf Health to determine what will be necessary to correct the failure, E) Large Systems: To be considered a large system the system trust serve a facility with a design flow of 10,000 gpd to 115,000 gpd. For large systems,you must Indicate either yes"or"no"to each of the following, in addition to the questions in Section 13. 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 drtnldng water supply ❑ d the system is locatad in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone tl of a public water supply well if you havO 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 16.304.The system owner should contact the appropriate regional office of the Department sma.nno Title50W9hepeaanFarm:8MudvASowmmDiapoASy1tem-Psge5a11 Feb, 29. 206 3: 16PM k 2863 P. 6 05/15/2013 WED 9:00 FA% 508 428 0815 W. Raveis ,RE Osterville Maxk Stanley �006/OZ7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Assessments 32 Beldan Lane PropertyAddmas Charles C.Case Jr. Owner .......,� -----�...� Owners Name Infaimrequired u Centen llle Ma 02632 �l1112013 required fiat®very - ...,,,.. page_ cKyrrown state ZIP code Deft of Inspe-Mon C. Checklist Check if the following have been done.You must indicate"yes°or"no'as to each of the following: Yes No ❑ 0 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? ❑ 13 Has the system received normal flows In the previous two week perfoe Have large volumes of water been Introduced to the system ref:e*or as part of this inspection? Were as built plans of the system obtalned and examined?(If they were not available note as NIA) W ❑ Was the Facility or dwelling Inspected for signs of sewage back up? ® ❑ Was the site Inspected for signs of break out? ® 0 Were aD system components,excluding the$AS,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 bfaaed 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)1 D. System Information Residential flow Conditions; Number cf bedrooms(design); 3 Number of bedrooms (aotual): 2- DESIGN.flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 SO OW-11flo IWO 5 dfGAed VMdM Ferro.$ubsWk08 Sewage U&poea 6Wem-Page 8 or17 Feb. 29. 206 3: 16PM k 2863 P. 7 05/15/2013 WED 9:00 FAX 508 428 0875 W. Raveis RE Doter'villa — Mark Stanley 1@0071017 Commonwealth of Maesachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Seldan Lane Property Addreas Charles C.Case Jr. Owner owners NaMB - requIred atr for Centerville Ma 02632 4/11/2013 r CkylTown state 21p Code Hate orinspeolion D. System Information Description: Number of current residents: 0 ~-~T-- Does residence have a garbage grinder? © Yes No Is laundry on a separate sewage system? iif fives separate Inspection required) ❑ Yes No Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes 0 No Water meter readings,If available(last 2 years usage(gpd)): petait Sump pump? © Yes 0 No Fab 2013 Last date of occupancy: Date Commercial/industrial Flow Conditions; Type of Establishment: �---�- Design iiow(based on 310 CMR 16.203): Gallons per day(pd) Basis of design flow(seaWpersonslsq.ft, etc.): �- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tito 6 systern? ❑ Yes ❑ No Water meter readings,it available: - w--w -- 15tr�e riHO 7WsSDfadelTepsoknForrr:SubsudamlknpoDlw4salSyslem Pape7M17 Feb. 29, 2C16 3: 16PM k 2863 P. 8 05/15/2013 WED 9)01 FAX 500 420 0875 it. Raveis RE Oeterville yam•+ nark Stanley �0081017 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Beldan Lane Property Address Charles C.Case Jr. Ownar Owner's Name^ iequired;fo Is Centerville Ma 02632 4111/2013 regained for every ,...„•., page, cttylrown Stela Zip Code Date or lnspectlon D. System Information (cost.) Last date of occupancy/use: gate - Other(describe below): General Information Pumping Records; Source of information: - --� �— Was system pumped as part of the inspectlon? ❑ Yes tZ 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 ay-stern(yes or no) (if yes,attach previous inspectlon records,if any) ❑ Innovative/Alternative technology.Attach a copy of the ourrent operation and maintenance con tract(to be obtained from system owner)and a copy of latest Inspection of the ilA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Ll Other(describe): tens•??rlo Tills 5 ONO 1Ws0Wm Vow subsurface Sewage Mwasl Wilen•Pegs A 017 Feb, 29. 206 3; 16PM No. 2863 P, 9 05/15/2013 W$A 9101 FHS 508 028 0875 W. laveie AB Oster Ville — Hark Stanley 0009/017 Cwnmonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Befdan Lane Prope(ty Address Gharles G.Case Jr. Owner ownees Name requIredon Centerville Ma 02032 a/11(2a13 required for every ......,��-- —sago. a tyfrown State �Ip Oode hate of Inspection D. System Information (cont.) Approximate age of all components,date Installed(if known)and source of Informallon: orr Ina... _I system 1980 par town records Were sewage odors detected when arriving at the site? © Yes 0 No Building Sewer(locate on site plan)' Oepfh below grade: 2 feet Material of construction: El cast iron ®40 PVC CI other(explain): --~� Distance frorn private water supply well or suction line: 10+ feet Comments(on condition of joints,venting,evidence orf leakage,etc.): Joints ok,no leakage,vented through roof Septic'rank(locate on site plan): 1.5 Depth below grade, foot - Material of construction: ®concrete ❑metal [I fiberglass ❑polyethylohe ©other(explain) If tank Is metal,list age: years Is age confirmed by a Cerlif4cate of Compliance?(attach a copy of certificate) © Yes El No 01menslons: 1000 allarls Sludge depth: 6° {spry 11110 iIllsaOMWlftgo wfomSdwdwe$swageOlsMal$ys(em•Pag090117 Feb, 29, 2C16 3: 16PM k 2863 P. 10 05/15/2013 WED 9:02 FAX 508 429 0875 W. Ravais RR Osterville 4— Mark Stanley 2010/017 Commonwealth of Massaehusettg Title 3 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Beldan Lane Properly Address Charles C.Cass Jr. _ OWnet Owner's Name qu ra dfof very[s Centerville Ma 02632 4/1112013 Page. f r pode Pate o1 inspwlgn & c➢ylrown state zip D. Systern Information (cant.) Septic Tank(coM) Qistsnce from top of sludge to bottom of outlet tee or befflib 31 Scum thickness S" Distance from top of scum to top of cutlet tee or baffle 611 Qistence from bottom of scum to bottom of outlet tee or battle 10° How were dimensions determined? opened covers,took measurements Comments(on pumping recommendations, inlet and outlet tee or bade condition,structural integrity, Itcluld levels as related to outlet Invert,evidence of leakage,etc.); Wank needs to be cleaned soon and again ebety 2 years for proper maintenance.Water level wee even with outlet invert,tank was not leaking and was structurally sound.Outlet baffle was Intact and inter good condition. I Met and outlet covers are on risers_ Grease Trap(locate on site plan): Depth below grade: feet - Material of construotion_ El concrete [I metal ❑fiberglass ❑polyethylene ]other(explain): Dimensions: ------ - Scup, 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 f5int,1111e T11e50nlof01WpWUwtF0rm:SUMU440980 aga013pomn18yA1411-P4go10or17 I Feb. 29. 206 3: 1/PM k 2863 P. 11 05/15/2013 WED 9:03 FAX 500 428 0875 W. Ravais RE Daterrrille — Mark Stanley �bii/017 OL Commonwealth of lirtSssachusetts Title 5 Official Inspection Form Subsurface sewage'Disposal system Form-Not for voluntary Assessments 31 Belden Lane w Property Address Charles C.Case Jr. Owner ownEWs Nameinformatio required for Centerville Me 02632 4h112013 requA�ed for every —,— page, cllyfrown state zip code rate of lnspear{on D, System Information (cunt.) Comments(on pumping recommendations,Inlet and outlettee or baffle condition, structural integrity, liquid levels as related to outlot invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: - Materlal of construction, ❑ concrete ❑ metal fiberglass El polyethylene ©other(explain): Dhensions: - Gapacity: -- Design Flow: gallons per day Alarm present ❑ Yes Q No Alarm level: Alarm In working order. Cj Yes E] No Date of last pumping: Date Comments(condition of alarm and ftaat switches, eta.): "Attach copy of current pumping contract(required).Is copy attached? ❑ Yes © No ftl ,111D TNe 6 oNclel mepeC&P Form abbsuAwe eww"o,dlspesw aysrom•pgge 110117 Feb. 29. 2C16 3: 11PM k 2863 P. 12 05/15/2013 WED 9:03 FAX 508 d28 0875 W. RaVdis RE Osterville — Mark Stanley 1@012/011 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Beldan Lane Property Address Charles C.Case Jr. Qvlrter Owner's Name Informrequired a Centerville Ma-...... 02632 4/1112013 require®for every Page, Clt TM%n State Zip Code Date of Inspootion D, System Information (cont.) Dishibullion Box(If present must be opened)(locate on site plan): Depth of(quid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Distribution box was functioning as intended. Pump Chamber(locate on site plan): Pumps In working order. [] Yes [3 No Alarms in working order: [1 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: 15tu•1 i/10 �Ib 6 MAO Irupsdiw Form ftsuifece Sawepe Diapo9al SY&M 969a 12 of 17 Feb. 29. 2C16 3: 1—/PM k 2863 P. 13 05/15/2013 WED 9104 PM 508 426 0075 W. Raveio RE rleterville --- Hark Stanley 0013/017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage blsposal System Form Not for Voluntary Assessments 32 Beldan Lane Property Address Charles C.Case Jr. Owner Owners Nameinfor - ,qu; d f is Centerville, Ma 02632 4/11/2013 required for every _ page. Citylrown Sate Zlp Cade Date of inspection D. System Information (cunt.) Type: leaching pits number1 xD00 alb Ions ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions; --�-- [� overflow cesspool number: © Innovative/alterneWe system lypelname of technology: ------------- Comments(note condition of soil,signs of hydraulic More, level of pending,damp soil, condition of vegetation,etc.); Leach pit was found to have 15 of V/aterwith a stain One only 1'higher_ Cesspools(cesspool must he pumped as part of inspection)(locate on sRe plan): Number and configuration Depth—tcp of Ilquld to Inlet Invert Depth of solids layer Depth of ecum layer - Dimensions of cesspool Materials of construction Indication of groundwater Inflow ❑ Yes rj Nc 151AD-»h o Tpta 80&W hdpoal mNfm GLftW&=G"o Ugmsal Eyatem-Pape 13 ai 17 Feb. 29, 2C16 3: 11PM k 2863 P. 14 05/15/2013 VM0 904 IrAx 506 429 0875 W. RaVeia RE 05terville — Makk Stanley Q0141017 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3213eidan Lane Propedy Address Charles C.Case Jr. Owner OwneYs fame — -- — informallon is iequln3d for every ervi Centlle Ma...__ 02632 4/1112013 page. Cftyrrown slate Zip 0nde Date oflnspeouan D. System Information (cont_) Comments(note condition Df soil,signs of hydraulic failure,level of ponding,condition or vegetation, etc.): Privy(locale on site plan), Materials of construction; ---�-- ©lmenslons �--- Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation. etc.): Ift•i it r0 Tkk 9 MW 1mp"M FWm'Subwrrana Smsmga Pkpoo!System-Page 14 or 17 Feb. 29. 2C16 3: MM k 2863 P. 15 05/L5/2013 WED 9105 FAX 508 428 C875 w. Rave}.B Itx Ostenv111e taazk Stanley [40151017 CommronweWth.of Maus—achusetxs `title 5 Official Inspection Form Subsurface Sewage D9sposai System Form-Wat for Vciuntary Assessments 32 8eldan lane propedy Address• Charles C.t;ase-Jr. ___v �- - Otsr►er Ow�rer's Name lnliomrau0n Isreq& CBnffirvitle Ma_ A2632 4111/ 013 Me- for eVey CIIyrr"n — MAL- Iap coda [Date ar Inspection - D. System Infolrmetton (cont.) Sketen of sewage btsposafsystEm: Provide:a view of the sewage disposal system-,including ties to -at least twe permarierttreterenee landmarks or benchmarks,Locate all wells W.ithin 100 feet.Locate where public waterapply enters the building.Cheok one qfthe boxes bebc hand-sketch in the area balaw drawing attached separatety 3 —� zz lens•+1Na 'fI1Mapm mpecUmr�r�.3uUauibea8stiwgaPhpAddSs/slemVFaeo.SAdr,7 Feb. 29. 2C16 3: 11PM No. 2863 P. 16 05/15/2013 WXb Si05 FAX 500 428 0875 W. Raveis XL ogte=ville — Mark Stanley 20161017 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Betdan lane prop"Address Charles C, Case Jr. Outer owners Nam® Is requirefnf�rmd a Centerville Ma 02632 4111120'13 required for every' �. , pie• city/Towe &fate Zip Code Dale of Inspection U. System Information (cont.) Site Exam: © Check Slope ❑ Surface water © Check cellar ❑ Shallow wells Estimated depth to high ground water: t2+— feet Please Indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on rocord If checked,date of design plan reviewed: 6I4/1980 _ pate ❑ Observed site(abutting propertylobservatlon hole within 150 feet of SAS) �] Checked with focal Board of Health-explafn: ❑ Checked with local excavators, Installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Design plan indicates that no groundwater was observed at 12'and system is designed to have a ssperation of 6`+between bottom of 8.8.5.In adjusted.water table,. Before filing this inspec Tian Report,please see Report[Completeness Checklist on next page. t5igs 11110 ntaSOWaiin rrwnFom,sucaurTscesewe$aukvosa1$y*m-Pap IWO Feb. 29. 2C16 3: IIPM Vo. 2C63 P. 17 05/15/2013 WED 9:06 FPB 508 428 0875 W. Raveis RE OstervMe — Walrk Stanley 12017/017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Belden Lan® Properly Address Charles C.Case Jr. Owner Owner's Name information Is entenrilCe Ma 02632 411112013 required/oravey — . page, Gityrrown State Zip code Date of Inspectlan E. Report Completeness Checklist Inspection Summary:A,8,C. A,or E checked Inspection Summary D(System Failure Criteria AppliCable to All Systems)completed ® System Informatlon—Estimated depth to high groundwater Sketch of Sewage Disposal System etther drawn on page 16 or attached in saparate file 16r�s 11110 seta 50nel insPaemn Fwmw pisposaSysI -Page t7Ci7