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HomeMy WebLinkAbout0064 BENT TREE DRIVE - Health 64 BENT TREE DR, CENTERVILLE - A= 168-024 No. 42101/3 ORA ESSELTE 10°!a 0 0 0 0 lay � ,� ,, - ^� -t t o� � ��. f` �; i' r-. ,. i �; 1 �- �': t c r. +; 4 e n liq�3� y`� q � � Lower Floor 64 Bent Tree Dr Fireplace I Mechanical room 0 Living Room Bathroom Laundry Closet Closet & under stair Storage Stairs To IMain Floor Kitchen Bedroom a, L _o U Lower Entry Main Floor 64 Bent Tree Dr Door to Eat in Kitchen Fireplace Back Deck Kitchen Living Room Closet Bathroom Main Entry Closet Office/ Den N Bedroom _o U n o LA fD Upper Floor 64 Bent Tree Dr a, 0 tM m o L 3 O N M L Bedroom I a) rr E O L � ^^O N U n O N M K Closet r Bathroom as Landing Open to below Closet ( Bedroom o o L � 0 3 rD L � cu V) r+ O L % O aJ (D No. [ Fee �100PW THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes r Zipplitation for -isposal 6pBtrut Construction Pffmit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C �.. �rK--VC Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �- L� (G/►✓�il.� (p�� J,,� l Installer's Name,Address,and Tel.No. .rp6- 77 -G YG G Designer's Name,Address,and Tel. �� 413 Toa- MA Type of Building: Dwelling No.of Bedrooms FD(,� Lot Size I sq.ft. Garbage Grinder( ) Other Type of Building f/.F C/(f No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) � gpd Design flow provided tls gpd Plan Date t 6 9 � Number of sheets_) Revision Date 4,4109, Title Size of Septic Tank er 'A X, Type of S.A.S. f�GY/� GGI.�c� ChgzPJ-1S Description of Soil_ - of k d 9'C S ��e/y'i MI ,S'4 4CJ Nature of Repairs or Alterations(Answer when applicable) rill eXcS�i/n i. L` 57, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal S' ed Date D Application Approved by Date I Application Disapproved by Date for the following reasons Permit No. Zo I I 3 fb Date Issued 22 ! t r j ,t om ��, 1 # `' No.`.. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered incompute� r: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS a; 01ptlYiLatiOTY for ;B19tlOQaY *pstPm COlIBtrUctiolY Permit Application for a Permit to Construct( ) Repair A Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /C Owner's Name,Address,and Tel.No. ��/, Z-,' Assessor's Map/Parcel Installer's Name,Address,and Tel.No. j'p&- 7X-G YG,j Designer's Name,Address,and Tel.No. -��K 13, AIX MA Type of Building: Dwelling No.ofBedrooms F�,r/` Lot Size sq.ft. Garbage Grinder( ) Other Type of Building r�s'�,/�Q�S�No.ofPersons Showers,( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /7 gpd Design flow provided Cf s� . �' gpd Plan Date i. , �,, 7 9 )p J4 Number of sheets Revision Date /Aa Title 'Size of Septic Tank Type of S.A.S. ri.- Description of Soil 7 t — <<���It r Nature of.Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt " ? Si e Date Q Application Approved by Date S?sa e ^ Application Disapproved by Date for the following reasons Permit No. Z j�Q—?I to Date Issued Z Z p 1 --- ----------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by at �� �� �j�� 9,,IBC has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No. S/(o dated Q/ (! Installer /y / /�� Designer #bedrooms Approved design flow C gpd The issuance of this permitN not be construed as a guarantee that the system will fur;cti a designed. r Date InspectorL --------------------------------------------------------------------------------------------------------------------------------------- No. �l�IT t� Fee �J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(gyp) Upgrade( ) Abandon( ) System located at 441 /-eo„��/� j211 0 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. r{ Provided:Construction must be completed within three years of the date of this perm' . Date i —1 7A)1 q Approved by i TOWN OF BARNSTABLE LOCATION4� — F'Q 5,�,_ C' SEWAGE# �1 VILLAGE Ce"• rr-c.3 15 ASSESSOR'S MAP&PARCEL o`Z INSTALLER'S NAME&PHONE NO.-R t-C_ CA ka.4- lr.- 92o!�A SEPTIC TANK CAPACITY 1 CX6&*L, ►A-10 w kU_SE_5 LEACHING FACILITY:(type C**,-,6e4S (size) /31)(33; -50r►N stcx-•ate t-, 'DBS o�.Al t-As .— NO. OF BEDROOMS OWNER C PERMIT DATE: COMPLIANCE DATE: -A61 Separation Distance Between the: y,(p 4W� Al' yy°Q e- 64C Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) '( Feet FURNISHED BYE^ 6e4l dot,'Pee.- ,i13 P - q 36` u ae' 6t` 1 ° ►l j�// Gay.►('�s f-�$vrG i�rs��S U ODO Town of Barnstable Regulatory Services Thomas F. Geiler,Director RARNMBMMAS& Public Health Division 1639- Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-86 -46 4 f/ Fax: 508 90-6304 .Date: 2gZ Sewage Permit# Assessor's Map/Parcel Installer& Designer Certification Form Designer: �r'`,� °"Z ''J Installer: Address: YD• �x 71,f Address: . . Y r^ was issued a permit to install a (d te) (installer) septic system at �°r"fT���Q2 �U�tcE based on a design drawn by (address) dated � 9 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required was inspected and the soils were found satisfactory. 0,6 OF f,,q \ TEhENCE cyN !a M. a (Installer's ur " HNYESCn tJo. 979 , ��G15TE- k S 1 '!T W PN (Designer' Si re) (Affix Desi` ETV amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\ofce forms\designercertification form.doc madison avenue • cape cod strategic marketing & planning 22 August 2019 Jim Parziale,R.S. Health Inspector Town of Barnstable Department of Regulatory Services Public Health Division 200 Main Street Hyannis, MA 02601 Re: 64 Bent Tree Drive,Centerville Dear Jim: Per your request,please consider this my affidavit regarding my house. My husband and I purchased 64 Bent Tree Drive,Centerville, MA 02632 as a 4-bedroom home in June of 2006. That is prior to the 4 July 2008 change of designation to this immediate neighborhood. In my discussions with you,you have confirmed that the.flow for the septic is more than adequate for a 4- bedroom home and that in your research you believed it to be a 4-bedroom house. Further,the house was built as a 4-bedroom home with 2 bedrooms on the top floor,1 on the first floor and,1 on the basement level in 1962. There is another room that could be misconstrued as a bedroom(my office)on the first floor and you have advised me to widen the doorway so that no door can be put there, however,there is not enough space for a full 4'opening. We will speak to someone and get a proposal of what and how to open the entrance. The assessor's office calls this a 4-bedroom house,the paperwork you have has shown it to be a 4- bedroom house and 1 am requesting that we put this matter to bed so that future owners will not have this ongoing question. .1 cannot change how.the house was built. In closing, based on our conversations,I listed this house for sale as a 4-bedroom and in having to put in a new leeching field the engineer has made plans for a 4-bedroom. If you would like to come and do a walk through, I can show you how it cannot ever have been less than a 4-bedroom home(we are enclosing amateur floor plans). Thank you for your time and attention in this matter, Lisa Conrad lisp Conrad 508.419.1376 fax 508.419.1382 64 bent tree drive 9 centerville, ma 02632 IVGW Floorp(cLo ; E� .W. : . :. . - ,: _�.__ .._ • _.:,._ -... . 110600 )00 �nrr.TkE�D�_ �Z KlrcNr� I_. . i . RAC. YC - -I-- , i... .i° .. . .. :4.�+bmnvnn®ivcver.0. f AfrvR 4i F \ D3 -mom �•••« ( t �:✓wn..'�+n.vMN+Y.e. nn re,.+.v.a,.inw:.!.X+wC..!!. +n, Y:..iY'na�ei'+:!Ye>�w..ew. //jJ y�"�S�c3"� ,�77`r .:,�.,;�..,.�:�:,::���,,.�>,.���,.,,..K...�..�...=...m..�,.,,�x_.�,,M,,,m....�.»r'..-,.M.,��.M,w...�...._„».,�-.�.��.��.�U,p.,.. .���4:,...,.��,.�wt. : ,�:,,, .µ�t��.�. ..a H:,�«,�-,..,.»K�..�„�. . -._�,,..... .. -• fi a. E u �. V. .. P` a S �:� � r a � i �G a 1 `, mow^-..`� 1 ; i I ^ �� O -.�..:ru'i....r. /\\�\��/�/7� { {=1= �M"+..0.4 !x�+� �tiosiiwiix;ar. h\ Y� �as VV "' �( � Y. '� +u� � � }i '� A 4 � ., "� Ay� 1�jy+mryymW •�(`v x ,! } � � � yj� � v.idrr..w a. a..,�.�; �. f:.:�..vv, .�:..♦.aro._.�7 cio+x+4N:u.�.a»;w - s � � � _tvx.^T:..n, ..„M+.aty...,....,..«....,....� J. .,.w-�.s-rNVW.-n..�.,.....�....wnave��e.►u.....wnu�..r��..�ax��re.��-wsxar.;wsaarzrsr�+au�E-nax�..w�v .. 1 S 9YfY ASSESSORS MAP NO• M gr PARCELNO: OZ�/ No. -_... � Fma....��.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Diti-pniiui lVarkii Tomitrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair (04 an Individual Sewage Disposal System at: C Location- ,kddre s or Lot ----------------- ......................................................... wner o A e W ��u✓� �c v �;1 G6 v.�s AA-- t!1/► .�1 tom... Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............. ......__......-_.-_.Expansion Attic ( ) Garbage Grinder _ _)AM aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ----- w Design Flow.............. -----.-.--.--.-gallons per person per day. Total daily flow-.._.......-.,?__ ...---.--------gallons. W Septic Tank—Liquid capacity/412 galIons Length---------------- Width................ Diameter---------------- Depth---------------- * Disposal Trench—No- ---------------_-- Width........... ..... Total Length-------- ...�...... Total leaching area....................sq. ft. Seepage Pit No---------1......... Diameter-------Via....... Depth below inlet------ ----------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-----.-------------- Depth to ground water...--------....._------- GT, Test Pit No. 2................minutes per inch Depth of Test Pit........-.--.-.----. Depth to ground water........................ w .....---•...----•---••--••-•------------------------------------------------------------------------...............-......................................... 0 Description of Soil...............•-----••----------------------------------------------------------------------------------------------------------------------------------------------•-- x c, x ------•-•-••----- --------------------------------------------------------------------------------------- --------------------------------------------------- --------------------------------------- U _ Nature of Repairs or Alterations—Answer when applicable------l0d------- ........,1.� 40-,�r'.�........�: :. .—AVr ..........f•-��T---��-�------�-------- �------.----....T7AJ.-------�`�cS��-�►� ................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s en issu d b the board of health. Signed ........... Application.Approved BY ------------------ ----- - 1� Mte Application Disapproved for the following rea.ron.r: ...................................... ..... .. ....._.......................... . ----------------------------------------------------------------------------------------_.._---_---------...------...-......_...__------...-------------------------------------------------- _------------------------------------ Permit No. ........ ---------- -------- - ------ Issued "✓ `' �--__ Dare ,y l6 � Y Z 1No.... �.`.� Y Fss....3 .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 1 VVftrtttion for Uhnpo!3ul Work,6 Toutitrnrtion runtit Application is hereby made for a Permit to Construct ( ) or Repair (>4 an Individual Sewage Disposal System at: ........--•...--- ••. . •-•-- ---------••-•------•----•-•--•-------- -•-- / Location-Address Lot No. Owner Ad ire 1i ry S — a i -----••••• -••---••-----•--------•-•--.�.._ -------------�'rc�1i�------------------ --'--`-=�------`=`5--- .. installer � Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-----------------------_-__-___-___---..-.--Expansion Attic ( ) Garbage Grinder .( r),atl© aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q Other fixtures -_------------------------ ----------------- WDesign Flow............... ----------------gallons per person per day. Total daily flow--------------_2 .4-----------------gallons. Septic Tank—Liquid capacity_/ 4!0-gallons Length---------------- Width---------------- Diameter._.__ ---------- Depth---------------- W Disposal Trench—No. .................... Width-------------------- Total Length.----_-____- ----_ Total leaching area----------_.........sq. ft. Seepage Pit No................... Diameter........e�4q._..... Depth below inlet......(I.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit___-----_-____---._. Depth to ground water........................ (% Test Pit No. 2................minutes per inch Depth of Test Pit---..---.--_--_--__- Depth to ground water........................ Descriptionof Soil......................................................................................---------------------------------................................................ W x .............................................................. ------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable...___% .Q_---.--A -__.._-_/�0A.-..............�:-...`........i_r . Agreement: - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued bylthe board of health. Signed ... - - - _ r--- --------------------- -----I------------------------------- Application,Approved By -------------- ---- ---- --- {•------------------- `~ 7 Dace Application Disapproved for the following reasons- ------------------------------------------- ---------------------------------------------_------------_._....-------------- ...........................................................................------------........------------------------------.....---....---......._...---..............._..----------------------- --------------------------------------- �...+ Dare �.�.�` Permit No. ..... ........ Issued "'-. ""` Dare 1 -- —. ————————————————— ——— --———— —a--- ----- --«:..--- — -,.-- THE COMMONWEALTH OF MASSACHUSE17S 6Zy BOARD OF HEALTH TOWN OF BARNSTABLE CLe>r#i i�tt#e of V.1, ttncE THIS IS TO CERTIFY.—That the Individual Sewage Disposal System constructed ( ) or Repaired ( �) by ----------------------------------------------- --------------------------------------�---------...._..._...------------------------------------------------..._... at lo..l � �O �--. L --------................. -... - has been installed in accordance with the provisions of TIT hgiS�tate Environmental-Code as described iA the application for Disposal Works Construction Permit No. -. !� --- f dated ��5 �,T _. (f, THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...�� - -- -- --- ------ Inspector .. ,. �" ��--.�--..'° _ _i.. `.gip——— ——— ——— ..'°'°` ' �C. �--- - - -THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q�4`7 -�-� TOWN OF BARNSTABLE �a No............. .......... FEE......... Elionood Nog-4 Tontrudion ran it Permission is hereby granted------------ ------�_-_G-'.xt._.0 Ctr -------- �� �c"7��``I to Construct ( ) or Repair ( —)'an Individ�ial Sewage Disposal System atNo................................................... '..V--••- .'C..........................................................I/.....--...' ..�i.................... strcek/���----�� _ as shown on the application for Disposal Vhorks Construction Permit,�lNo�."' _;fllated-.��__..�-�-_r..� -- ^� - ---------------------------- ` JJ;y� Board of Health DATE------------ ---------------•----------- -----�' --------- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION L"t`I ��� �� rJ/l � SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. OZGFU l4 6AJfJl i yam- SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /9 i (size) NO. OF BEDROOMS --7 PRIVATE WELL OR UBLIC WATER BUILDER O ( d/1's1 Q Uy —L DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No fgr _ of Town of Barnstable Barnstable Inspectional Services Department ;efic;3cj BAF2NA BLF— sbgp, ' Public Health Division ,� o Ar�O f"Ay s 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.WKoan,CHO CERTIFIED MAIL#7012 1010 0000 2848 2503 July 22, 2019 CONRAD, LISA M & WESTON,NEIL C 64 BENT TREE DR CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 64 Bent Tree Drive, Centerville, MA was inspected on 06/19/2019 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S.,-CHO Agent of the Board of Health Q:\SE11T1C\Tit1e V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\64 Bent Tree Drive Centerville.doc 'T�rq� P., Town of Barnstable • EwxrisrnBLE, Inspectional Services Department TfD µAti� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) it/Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t �y " �,•° 64 Bent Tree Drive (-Q Property Address {j Lisa Conrad ; Owner Owner's Name .. information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection F ' 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. Imngoutforms A. Inspector Information S'l 3�j(Q a. filling out forms on the computer, use only the tab 'Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane " Company Address Centerville Ma 02632 City/Town State Zip Code 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails 6/19/2019 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts r= Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ 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 ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ® ❑ 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for a//inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: i Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (/e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): 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 5. Building Sewer(locate on site plan): Depth below grade: 4 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3.5 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: 6" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" lt Distance from bottom of scum to bottom of outlet tee or baffle 11 How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was structurally sound, water was even with outlet invert, tank was not leaking. Tank is 3.5' below grade with inlet and outlet covers on risers. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �r 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was video inspected from outlet of tank. Pit was found to be full into inlet pipe resulting in a failing inspection. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/2 612 01 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �v 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 0 0 �2 2� G + t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f; 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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 not established. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Bent Tree Drive Property Address Lisa Conrad Owner Owner's Name information is required for every Centerville Ma 02632 6/19/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I I 1 COMMONWEALTH OF MASSACHUSETTS w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION h� C bb C,�'9M v0y 350 MAIN STREET sa WEST YARMOUTH,MA 508-775-2800 i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMINTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM s ! r PART A �'i w`'ry .�� CERTIFICATION en MAP 168—PARC 024 c w Property Address: 64 BENT TREE DRIVE Ev^ CENTERVILLE,MA 02632 _ =r Owner's Name: BOUCHER,RICHARD ry r— Owner's Address: 64 BENT TREE DRIVE syt CENTERVILLE,MA 02632 , 1 Date of Inspection AUGUST 15,2005 5� ��7i Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Eval `on by the Local Approving Authority Fail Inspector's Signature: Date: , Q,SC 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 th.,-system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments 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. Title 5 Inspection Form 6/15/2000 1 T Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: .( I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15,2005 C. Further Evaluation is Required by the Board of Health:N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance ** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15,2005 D. System Failure Criteria applicable to all systems: N/A 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 pit is less than 6"below invert or available volume is less than%z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS;cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 H 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 is 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 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15, 2005 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,including 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)has been determined based on: Yes No ✓ 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(3xb)] Title 5 Inspection Form 6115i'2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15, 2005 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: N/A Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A—NOTE:MAINTENANCE PUMP AFTER INSPECTION. Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1995 PERNUT#95-643 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 ,t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15,2005 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 16" Materials of construction: Cast iron ✓ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): If Depth below grade: 28" Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000-GALLON PRE CAST Sludge depth: 6" Distance from top of sludge to the bottom of outlet tee or baffle: 24" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: ASBUILT,PROB&TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK HAS OUTLET BAFFLE,MAIN TANK AND COVERS AT 28"BELOW GRADE. NO SIGN OF BEING OVER LOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: _ concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15,2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N/A (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: N/A (locate on site plan) Pumps in working order(yes or no Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15'2000 8 i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: T3Pe leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING ONE 1000-GALLON PIT PRECAST PIT IS 57"BELOW GRADE,COVER AT 28—28"WATER STAIN LINE AT 34". NO SIGN IN PIT OF SOLID CARRY OVER OR OVER LOADING. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: _ Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil.,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 14 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 4— Observation 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: TEST HOLE 14'NO WATER. TEST HOLE Y BELOW BOTTOM OF PIT. BOTTOM OF PIT AT I F BELOW BOTTOM OF PIT. T Qo/7T� Title 5 Inspection Form 6/15/2000 11 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 BENT TREE DRIVE CENTERVILLE,MA 02632 Owner: BOUCHER,RICHARD Date of Inspection: AUGUST 15, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 14 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: TEST HOLE 14'NO WATER. TEST HOLE Y BELOW BOTTOM OF PIT. BOTTOM OF PIT AT I F BELOW BOTTOM OF PIT. 1 Qo/T� Title 5 Inspection Form 6/15/2000 11 /' TOWN OF BARNSTABLE LOCATION t �r 7if'£ �'P SEWAGE# VILLAGE C £ tiT ASSESSOR'S MAP&LOT »ST,4d�R'S NAME&PHONE NO. /� �� [/ ! IV C G SEPTIC TANK CAPACITY T/C /ti 5"ia E C l o sts LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 1 BUILDER ORq !J o U C lT E/f PEPAG-'-DATE: Y"�C, • d S� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by rur a ac 0 0 Property Location: 64 BENT TREE DR CENT MAP ID: 168/024/l I Vision ID:10937 Other ID Bldg# 1 Card 1 of 1 Print Date 02/08/2001 rsx emen Description omntera a a em n e ype p - evc ement Description odel 1 Residential Heat rade C C Frame Type Baths/Plumbing tories 1.5 1/2 Stories ceupancy CeilingfWall ooms/Prtas xterior Wall 1 14 Wood Shingle Vo Common Wall 12 2 Wall Height oof Structure 3 able/Hip ;Loof Cover 3 sph/F GIs/Cmp .: >>;.;,-r. nterior Wall i 8 Typical Element Descrip tion Pactor 2 nterior Floor 1 0 Typical omp ex 2 Floor Adj Unit Location eating Fuel 2 Oil FHS eating Type 9 Typical umber of Units BAS 2 C Type 1 None umber of Levels BMT /o Ownership Bedrooms 5 5 Bedrooms Bathrooms 1.5 1/2 Bathrms 111 Full+1H na i.Base Kate Total Rooms 7 7 Rooms ize Adj.Factor 1.04131 ade(1)Index 98 Bath Type dj.Base Rate 898 Kitchen Style ldg.Value New 2,474 38 at Built 962 ff.Year Built 1980 rml Physcl Dep 7 uncnl Obslnc on Obslne a pecl.Cond.Code -` >. pecl Cond o e Description ercen a e erall%Cond. 83 single Fam Luu eprec.Bldg Value 76,800 . .:.;:,rs. "� �">,k �;,4.>„ ;.s' ?{i5 :.::^n.�::i 41£#s .'.{..,,F ;i`k�#° s,.„.i�.;,ii... r ,:.rr,.. E....r+• l,?:, 1�,axs"„b Code. Descriprion UB units Unit Frice yr. upKt Youndpr. Ya ue BSMtLIv- xc BGAR Bsmt Garage B 1 4,000.00 1980 1 100 3,300 BLAI Bsmt Liv-Good B 500 31.50 1980 1 100 13,100 aW .a11'-1, d-��,"..x1..' i} '� �r`` code •Description LIVIngArea CirosSArea & Area unit Costn prec. ralue irst k loor 45.95 BMT Basement Area 0 988 198 9.82 9,698 FHS Half Story,Finished 692 988 692 34.31 33,894 WDK Wood Deck 0 96 10 5.10 490 v7,ease rea 1,8881 Ba I TOWN OF BARNSTABLE LOCATION o , 7 46 Z-1/r SEWAGE# VILLAGE C N 7— ASSESSOR'S MAP&LOT W&TA;61�'S NAME&PHONE NO. ,4 /8 0 SEPTIC TANK CAPACTI'Y S 0 -7- C /o LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER ORdWN-�E 13 O 0 C PEIE41T-DATE: Y"/� - d S- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ��R G V t3 :� 0 0 TOWN OF BARNSTABLE LOCATION LeV 26V'7X-f-�- o01&V-C- SEWAGE VILLAGE < F/i rr - ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ?-7Rxi I G(in1� yam= SEPTIC TANK CAPACITY /ve('J LEACHING FACILITY:(type) ram) (Size) [p X- (m 1 NO. OF BEDROOMS `� PRIVATE WELL OR UBLIC WATER BUILDER O �/► e Q�j��,q� DATE PERMIT ISSUED:DATE, COMPLIANCE COMPLIANCE ISSUED: � VARIANCE GRANTED: Yes No fg f _ Z/q'� � f � N 20 FT. MI NfirttliM F R;'N ukl._AR. OR CRAWL SPA(.-,[ � ��._M__ _ �i. � t �.+► .,.w J = 100-00 p �7 �Ik�t_Miltw� 10 FT, MINIMUM FROM SLRS � �A� OF tAL TECLE AN S AND r S +C'•.`..3SJ G �.. ,.,\, _ .._..._._—.... i.'.t//J-7 �; v t♦ �y Y`E i fp:J+�'» T�r'l�i ,`'Z'.!)R. WITNESSED BY 4" SGHEDUL� 40 P yr P P ! t, LOAN, aNt E ED MIN. PITCH t/8" PEP F � I � � � 2` Lgyc'R G SEPV:A ON HOU 1 I 4 f r r 1 fi t , R �i. i t_..._. 94.7 MAX, W i } , AS�Et, STONE w, .r NAX �Y l }� �I✓ a � f C. •y' �. ' ly ' !,'+Od life. I E .1.•-„«. ` !:I ��..� k N '"�. 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